VII.

NCP AND CASE STUDY

assessment

Nursing diagnosis

inference

planning

intervention

rationale

Evaluation

Subjective cues:

Objective cues: Decreased urine output UO- 50 ml Restless Delayed capillary refill Weight loss

Fluid Volume, Peptic ulcers deficient(isotonic) r/t to Active fluid volume loss(hemorrhage) Gastric erosion

After 30 mins of nursing intervention the patient will: Learn the disease process

Note of vomitus or drainage

Helpful in cause of gastric distress Changes in Bp

After effective nursing intervention the patient was able to: Demonstrate improved fluid balance as evidence by individually adequate urinary output with normal specific gravity, stable V/S, moist mucous, good skin turgor, prompt capillary refill.

characteristics determining

After an effective nursing intervention the patient will: Epigastric Demonstrate mucosal improved fluid balance as tears (Malloryevidence by Weiss individually adequate syndrome) urinary output with normal specific gravity, stable V/S, moist Hematemesis mucous, good skin turgor, prompt capillary refill. Fluid volume deficient

Mon itor V/S

and pulse may be used for rough estimate of blood loss Provides guidelines for

Monitor I and O and correlate weight changes. Measure blood/ fluid

fluid replacement

Potential exits

losses via emesis. Gastric suction Keep accurate record of subtotals of solution/ blood products during replacement therapy. Maintain bed rest; prevent vomiting and straining at stool

for overtransfusion of fluids, esp. when volume expanders are given before blood transfusion Activity/ vomiting increases intra abdominal pressure and can predispose to further bleeding

More easily digested and reduce risk of added irritation to inflamed tissues.

Caffeine and Provide clear/ band fluids when intake is resumed. Avoid caffeinated and carbonated beverages carbonated beverages stimulate HCL production, possibly potentiating rebleeding

Name: Mr. X Age: 24 years old Diagnosis: -facial grimace -pain scale of 6/10 (+)muscle guarding -unresponsive NURSING DIAGNOSIS Acute pain R/T Upper gastro intestinal bleeding AEB facial grimace muscle guarding behavior and being unresponsive. NURSING ANALYSIS The pathogen Helicobacter pylorus penetrates the mucosal lining of the stomach thus causing inflammation which later causes infection. With this situation, injury to the mucosa is inevitable. This injury will let hydrochloric acid and pepsin to seep into the mucosal lining which causes the pain experienced by the patient. GOALS AND OUTCOME NURSING INTERVENTION tion, characteristics, onset and duration, frequency, quality, intensity, and precipitating factors. 2)Monitor skin color and vital signs 3)Encourage deepbreathing exercise 4) Promote Bed Rest 5)Provide comfort measures, quiet environment and calm activiti assist in transitioning or altering drug regimen, based on the individual needs and protocol 7) Administer analgesics as ordered COLLABORATIVE 8)Collaborate in the treatment of underlying disease process causing pain 9)Provide for individualized physical therapy or exercise program that can be continued by the patient after discharge RATIONALE

1) To rule out worsening of underlying condition or development of complications. EVALUATION Goal Met: After 8 hours of Nursing Intervention , the patient reported a decreased of pain scale from 6/10 to 3/10, demonstrated increased interest in participating in the several activities and lessen facial grimace and muscle guarding behavior. Goal: the patient will report decrease in pain within 8 hours of Nursing Intervention As Evidenced By pain scale of 6/10 to 3/10, increase interest to several activities, and lessen facial grimace and muscle guarding behavior. 2)These are usually altered in acute pain 3)To distract attention and remove tension 4)To prevent fatigue 5) To promote nonpharmacological pain management 6) Increasing or decreasing dosage, stepped program helps in self management of pain. and enhances sense of control