Nursing Care Plan for Upper Gastrointestinal Bleeding NCP

Student Nurses’ CommunityNURSING CARE PLAN – Upper Gastrointestinal Bleeding ASSESSMENT SUBJECTIVE: “Napakasakit ng tiyan ko” (I’m having severe stomach pain) as verbalized by the patient. OBJECTIVE:     Abdominal guarding Rigid body posture Facial grimacing V/S taken as follows T: 37.3˚C P: 89 R: 19 BP: 110/ 80 DIAGNOSIS Acute or chronic pain maybe related to chemical burn of gastric mucosa, oral cavity and physical response such as flex muscle spasm in the stomach wall. INFERENCE PLANNING Acid, pepsin, and helicobacter infection play an important role in the development of gastric ulcers. The gastric mucosal barrier overlies the epithelium. The secretion of mucus and bicarbonate provides a first line defense in maintaining a near-normal pH on the gastric epithelium and protects the mucosal barrier against acid. Gastromucosal prostaglandins increase the barrier’s resistance to ulceration. The integrity of the barrier is enhanced by the rich blood supply of the mucosa of the stomach and duodenum. After 4 hours of nursing interventions, the Patient verbalize relief of pain and demonstrate relaxed body posture and be able to sleep or rest properly. INTERVENTION Independent  Note reports of pain, including location, duration, and intensity (0-10 scale).  Review factors that aggravate or alleviate pain.  Note nonverbal pain cues.  Provide small frequent meals.  Identify and limit foods that create discomfort.  Assist with active and passive range of motion exercises.  Provide frequent oral care and comfort measures including back rub and position change. RATIONALE EVALUATION  Pain is not always present, should be compared with patient’s previous pain symptoms. The comparison may assist in diagnosis of etiology of bleeding and development of complications. After 4 hours of nursing interventions, the Patient was able to verbalize relief of pain and demonstrate relaxed body posture and be able to sleep or rest properly.  Helpful in establishing diagnosis and treatment needs.  Non-verbal cues may be both physiological and psychological and may be use in conjunction with verbal cues to evaluate extent and severity of the problem.  Food has an acidneutralizing effect and dilutes the gastric contents. Student Nurses’ Community Collaborative  Provide and implement dietary modifications.  Use regular than skim milk, if milk is allowed.  Administer medications as indicated such as analgesics. Small meals prevent distention and the release of gastrin.  Specific foods that cause distress vary among individuals. Spicy foods, alcohol, and coffee can precipitate dyspepsia.  Reduces joint stiffness, minimizing pain and discomfort.  Halitosis from stagnant oral secretions is unappetizing and can aggravate nausea.  Client may receive nothing by mouth initially. When oral intake is allowed, food choices depend on the diagnosis and etiology of the bleeding. Student Nurses’ Community  Fat in regular milk may decreases gastric secretions. The calcium and protein content especially in skim milk increases secretions.  Helps relive acute or severe pain.