Nursing Diagnosis: Acute Pain related to tissue trauma, chemical irritation of the parietal peritoneum, and abdominal distension secondary to bowel perforation as evidenced by muscle guarding, rebound tenderness, verbalization of pain, distraction behavior, facial mask of pain, and autonomic or emotional responses (anxiety). Excess Fluid Volume Nursing Diagnosis and Nursing Care Plan, Pulmonary Embolism Nursing Diagnosis and Nursing Care Plan. Hinkle, J. L., & Cheever, K. H. (2018). The nurse can ask and observe for coping mechanisms that the patient uses. Avoid foods that trigger reflux such as fried foods, fatty foods, caffeine, garlic, onions and chocolate. Other Possible Nursing Care Plans. Signs and symptoms include: After a physical examination, diagnostic procedures like blood tests, x-rays, abdominal CT scans, upper endoscopy, or a colonoscopy may be performed to confirm the condition. The most common complication of peptic ulcer disease that occurs in 10% to 20% of patients is: A. Hemorrhage. The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes. Provide instructions to a dependable support person. Monitor for signs and symptoms of infection, such as fever and elevated heart rate. INCIDENCE OF COMPLICATIONS. The nurse includes that the most common cause of peptic ulcers is: 3. The patient will verbalize an understanding of pharmacological intervention and therapeutic needs. Learn how your comment data is processed. [Updated 2022 Aug 14]. Upper and lower origins of bleeding are the two main divisions of GI bleeding. Individual cultural or religious restrictions and personal preferences. She received her RN license in 1997. Administer prescribed medications.Give prescribed prophylactic medications, such as antiemetics, anticholinergics, proton pump inhibitors, antihistamines, and antibiotics. Desired Outcome: The patient will practice appropriate behaviors to assist with resolution of condition. 5 Peptic Ulcer Disease Nursing Care Plans, Peptic ulcer disease occurs with the greatest frequency in people between. ulcer surgery, gastric ulcer surgery, or peptic ulcer surgery) is a procedure for treating a stomach ulcer. DiGregorio, A. M., & Alvey, H. (2020, August 24). Treatment options depend on the severity of the condition and may include surgery to repair the perforation and remove any damaged tissue. Provide comforting techniques such as massages and deep breathing. Other choices are not related to ulcer formation. The most frequent cause of perforation in the elderly population is perforated appendicitis. This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. Patient will be able to appear relaxed and able to sleep or rest appropriately. Administer antibiotics as indicated.Antibiotics can help prevent and treat infection in patients with bowel perforation. It is either caused by bacteria or chemicals, can either be primary or secondary, and acute or chronic. Changes in BP, pulse, and respiratory rate. Take note if the patient is experiencing vomiting or diarrhea. This reduces the patients urge to vomit and gastrointestinal stimulation. Diet modification: small frequent feedings, bland meals, avoidance of caffeine, spicy, citrus, dairy products, and carbonated products. Assist the patient in understanding the condition and factors that help or aggravate it. She found a passion in the ER and has stayed in this department for 30 years. Deteriorating mental status can be brought on by hypoxemia, hypotension, and acidosis. 4. Perforation of the stomach is a full-thickness injury of the wall of the organ. Determine fluid balance every 8 hours. 3. Review and Administer prescribed medications.Examine the clients prescription, over-the-counter (OTC), herbal, and nutritional supplements to find any substances that might affect fluid and electrolyte balance or may be a cause of GI bleeding. Large gastric suction losses may occur, and the intestine and peritoneal space may sequester a significant amount of fluid (ascites). Jones MW, Kashyap S, Zabbo CP. Awareness and ability to recognize and express feelings. What are the signs and symptoms of bowel perforation? Nursing Diagnosis & Care Plan Acute Pain r/t Chemical burn of Gastric Mucosa Nursing Interventions - Record reports of pain including severity, location and duration. Encourage to increase physical activity and exercise as tolerated. Continuously monitor ECG fir dysrhythmias resulting from electrolyte disturbances. Reviewed: July 11, 2022. Patient Assessment Assess tissue perfusion. C. eating meals when desired. perforation of abdominal structures, laceration of vasculature, open wounds, peritoneal cavity contamination . Up to 15% of occurrences of perforation are related to diverticular illness. Low levels of Hgb and Hct signal blood loss. NURSING CARE PLANS: Diagnoses, Interventions, and Outcomes (8th ed.). gram-negative bacteria. The symptoms of bowel perforation can vary depending on the severity of the condition. Complete blood count, basic metabolic panel, and inflammatory markers should also be reviewed to assess signs of infection and determine liver and kidney function. 1.The client diagnosed with a gastric ulcer, pain usually occurs 30 to 60 minutes after eating, but not at night. To neutralize stomach acids and relieve pain.To help hasten gastric emptying time and reduce the occurrence of nausea and vomiting. 2. 3. Certain drugs can slow down peristalsis and contribute to constipation, i.e. Ensure infection control precautions are followed.Interventions that can help reduce infection in patients with bowel perforation include meticulous hand hygiene before and after handling the patient, the surgical site, and IV sites or catheters. Desired Outcome: The patient will maintain passage of soft, formed stool at a regular frequency. St. Louis, MO: Elsevier. Assess neuro status including changes in level of consciousness or new onset confusion. Saunders comprehensive review for the NCLEX-RN examination. Monitor the patients skin moisture, color, and temperature.Warm, dry, and flushed skin are early signs of sepsis. This process is called digestion and metabolism. Prepare for endoscopy or surgery.An endoscopy procedure may be necessary to determine the location and cause of GI bleeding. 5. Advance the diet from clear liquids to soft meals. Common causes of this disorder are recent abdominal surgeries and/or drugs that interfere with intestinal motility. Assess nutritional status.The nurse must take into account the current consumption, weight fluctuations, oral intake issues, supplement use, tube feedings, and other variables (e.g., nausea and vomiting) that may have an adverse impact on fluid intake. It is important to identify risk factors as it may influence the choice of medical intervention. The nurse anticipates that the assessment will reveal which finding? However, in the case of bowel perforation, contents of the bowel may leak out through the hole in its wall. Patients with this condition are instructed to maintain a low-fat diet and avoid caffeine, alcohol, nicotine, and dairy products. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Prepare patient for possible diagnostic tests. Nursing Care Plan 2.21.2007 NCP Upper Gastrointestinal / Esophageal Bleeding Bleeding duodenal ulcer is the most frequent cause of massive upper gastrointestinal (GI) hemorrhage, but bleeding may also occur because of gastric ulcers, gastritis, and esophageal varices. Observe output from drains to include color, clarity, and smell. She found a passion in the ER and has stayed in this department for 30 years. To stop ongoing diarrhea and minimize pain experience. Assessment of the characteristics of the vomitus. Evaluate the pattern of defecation.The defecation pattern will promote immediate treatment. Encourage patient to eat regularly spaced meals in arelaxed atmosphere; obtain regular weights and encouragedietary modications. Without prompt treatment, gastrointestinal or bowel perforation can cause: Internal bleeding and significant blood loss. The nurse must closely monitor the wound and perform dressing changes as instructed. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking. The most common signs and symptoms noted are heartburn, and indigestion. As directed, administer total parenteral nutrition (TPN) or tube feeds. Viral gastroenteritis also called stomach flu is a very contagious form of this disease. Reduce interruptions and group tasks to allow for a quiet, restful environment. Patient will be able to verbalize relief or control of pain. Initial gains or losses reflect hydration changes, while persistent losses imply nutritional deficiency. 3. Get answers to commonly nursing interventions and nursing management for effective treatment. In juvenile trauma patients, intestinal perforation occurs somewhere between 1% and 7% of the time. Certain food products exacerbate signs and symptoms of GERD. Additionally, patients may also experience signs of sepsis, such as confusion, dizziness, and low blood pressure. Nursing Diagnosis: Dysfunctional Gastrointestinal Motility related to inflammatory bowel disease as evidenced by frequency of stools, and abdominal pain. As tolerated, advance the patients diet. The nurse can monitor the vital signs of the patient, especially alterations in the blood pressure and pulse rate which may indicate the presence of bleeding. This article looks at . Assess the clients history of bleeding or coagulation disorders.Determine the clients history of cancer, coagulation abnormalities, or previous GI bleeding to determine the clients risk of bleeding issues. Maegan Wagner is a registered nurse with over 10 years of healthcare experience. 2023 Nurseslabs | Ut in Omnibus Glorificetur Deus! The nurse is assessing a client with advanced gastric cancer. Include also measured losses. Assess the patient for intake of contaminated food or water or undercooked or raw meals. 2. Diarrhea is often accompanied by urgency, anal discomfort, and incontinence. Management of this disorder includes temporary cessation of diet and intravenous nutrient supplementation. Encourage the patient to use abdominal splints.Splinting the abdomen can help reduce abdominal pressure before and after surgery when moving. Our website services and content are for informational purposes only. This includes measurements of all intake (oral and IV) as well as losses through vomiting, urine, and bloody stools. In general, putting the patient in a supine position alleviates the pain. The nursing care plan goals for patients with gastroenteritis include preventing dehydration by promoting adequate fluid and electrolyte intake, managing symptoms such as nausea and diarrhea, and preventing the spread of infection to others. Encourage adequate hydration (drink water) Encourage good oral hygiene. This usually requires admittance to an acute care hospital with consultation from a gastroenterologist and a surgeon. Plan rest periods and create a conducive environment for sleeping and resting.Rest increases coping abilities by reducing fatigue and conserving energy. This guide covers everything from pre-operative preparation to post-operative management. Patient will verbalize understanding of the condition, its complications, and the treatment regimen. To replace losses and improve gastrointestinal function. 1. Response to interventions, teaching, and actions performed. Patients experiencing a decrease in or lack of gastrointestinal motility commonly present with abdominal pain, bloating, nausea, vomiting, and constipation. Here are 6 nursing care plans for Peritonitis. Ineffective tissue perfusion associated with gastrointestinal bleeding can be caused by any bleeding from the mouth to the anus depending on the location. Encourage to increase oral fluid intake if not contraindicated. 1. Vomiting, diarrhea, and large volumes of gastric aspirate are signs of intestinal obstruction that need additional investigation. St. Louis, MO: Elsevier. 3. Limit the patients intake of ice chips. D. Combination of all of the above. Nursing Care Plans and Interventions 1. The nurse auscultated over the stomach to confirm correct placement before administering medication. In: StatPearls [Internet]. Thank you Marianne! There are three major causes of peptic ulcer disease: infection with H. pylori, chronic use of NSAIDs, and pathologic hypersecretory disorders (e.g., Zollinger-Ellison syndrome). waw..You did a great work. Reduced anxiety.
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