B. Clostridium difficile St. Louis, MO: Elsevier. This restores the electrolyte balance and circulation volume. This leads to various occurrences that cause discomfort and pain to the patient. Learning style, identified needs, presence of learning blocks. She received her RN license in 1997. 11th Edition, Mariann M. Harding, RN, Ph.D., FAADN, CNE. St. Louis, MO: Elsevier. Choices A, B, and D are proper interventions in providing pain control. A peptic ulcer may be referred to as a gastric, duodenal, or esophageal ulcer, depending on its location. perforation of abdominal structures, laceration of vasculature, open wounds, peritoneal cavity contamination . The gastrointestinal tract is the system responsible for converting food taken in through the mouth into the energy and nutrients that the human body needs. These notes are a-mazing! This lowers the danger of contamination and gives the chance to assess the healing process. Insert an indwelling urinary catheter and monitor intakeand output; insert and maintain an IV line for infusinguid and blood. Patient will be able to verbalize relief or control of pain. A 24 day old preterm infant was referred to our . Gastrointestinal bleeding StatPearls NCBI bookshelf. Antipyretics lessen the discomfort brought on by a fever. Administer antibiotics as ordered. Symptomatically, treatment includes dietary modification, an increase in fluid intake, and the use of laxatives. 1. D. Stomach. Cleveland Clinic. The abdomen may also feel rigid and stick outward farther than usual. The most common causes of acute intestinal obstruction include adhesions, neoplasms, and herniation (). Risk for Imbalanced Nutrition: Less Than Body Requirements, Nursing Diagnosis: Risk for Imbalanced Nutrition: Less Than Body Requirements related to metabolic abnormalities (increased metabolic needs) and intestinal dysfunction secondary to bowel perforation. Nursing diagnoses handbook: An evidence-based guide to planning care. Nursing Interventions and Rationales Assess and Monitor vitals Monitor for signs and symptoms of infection / inflammation to include: Fever Tachypnea Tachycardia Monitor for signs and symptoms of hypovolemia to include: Hypotension Tachycardia Perform detailed pain assessment Intestinal Perforation - StatPearls - NCBI Bookshelf These will lessen fluid loss and neutralize stomach acid hopefully preventing further irritation of the GI mucosa. Nursing Care Plan for Bowel Perforation 1 Risk for Infection Nursing Diagnosis: Risk for Infection related to inadequate primary defenses invasive procedures, and immunosuppression secondary to bowel perforation Desired Outcomes : The patient will achieve timely healing and be free of fever and purulent drainage or erythema Knowledge about the management and prevention of ulcer recurrence. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. The most common complication of peptic ulcer disease that occurs in 10% to 20% of patients is: A. Hemorrhage. Keep NPO and consider a nasogastric tube.The patient should be kept NPO and may require nasogastric decompression. Treatment options depend on the severity of the condition and may include surgery to repair the perforation and remove any damaged tissue. Evaluate the patients vital signs and take note of any patterns that indicate sepsis (increased heart rate, progressing decreased blood pressure, fever, tachypnea, reduced pulse pressure). Plan rest periods and create a conducive environment for sleeping and resting.Rest increases coping abilities by reducing fatigue and conserving energy. St. Louis, MO: Elsevier. The nurse is conducting a community education program on peptic ulcer disease prevention. Administer medications as ordered: antidiarrheals, pain medications. Monitor the patients complete blood count (CBC), hemoglobin and hematocrit (H&H) levels, serum electrolyte, BUN, creatinine, albumin levels. Other causes include medications, food poisoning, infection, and metabolic disorders. Prepare for endoscopy or surgery.An endoscopy procedure may be necessary to determine the location and cause of GI bleeding. Patient will verbalize understanding of the condition and its complications and alert the nurse or provider to signs of infection such as fever or wound drainage. Reduced renal perfusion, circulating toxins, and the effects of antibiotics all contribute to the development of oliguria. Based on the assessment data, the patients nursing diagnoses may include the following: Main Article: 5 Peptic Ulcer Disease Nursing Care Plans. Likewise, the continuous release of fluids may cause dehydration. There are various etiologies of constipation, including but not limited to certain medications, rectal or anal disorders, obstruction, neuromuscular conditions, irritable bowel syndrome, immobility, and others. Administer fluids and electrolytes as ordered. (2020). This includes measurements of all intake (oral and IV) as well as losses through vomiting, urine, and bloody stools. Wolters Kluwer India Pvt. Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). Medical-surgical nursing: Concepts for interprofessional collaborative care. The abdominal cavity can get contaminated by stomach acids, bacteria, and food particles, thereby predisposing it to infection and inflammation. For the third spacing of fluid, take measurements from the following: stomach suction, drains, dressings, Hemovacs, diaphoresis, and abdominal circumference. Bloating, vomiting, abdominal cramping, watery stool, and constipation occur as food and fluid are prevented from passing through the intestines. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). 3. C. Candida albicans Assess coping mechanisms of the patient.Coping mechanisms assist the patient in enduring, minimizing, and managing stressful circumstances. The treatment is symptomatic, although cases of bacterial and parasitic infections require antibiotic therapy. Patient will be able to verbalize an understanding of gastrointestinal bleeding, the treatment plan, and when to contact a healthcare provider. Assess complaints of pain, pain response, pain characteristics. Assessment of relief measures to relieve the pain. The patient will verbalize an understanding of pharmacological intervention and therapeutic needs. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. The patient will verbalize an understanding of the disease process and its potential complications. It is either caused by bacteria or chemicals, can either be primary or secondary, and acute or chronic. Assess what patient wants to know about the disease, andevaluate level of anxiety; encourage patient to expressfears openly and without criticism. Gastric Ulcer Care Plan.pdf - Nursing Care Plan Form Any bleeding that takes place in the gastrointestinal tract is referred to as gastrointestinal (GI) bleeding. To establish the diagnosis of peptic ulcer, the following assessment and laboratory studies should be performed: Once the diagnosis is established, the patient is informed that the condition can be controlled. Learn effective and evidence-based nursing interventions and nursing care management strategies to improve patient outcomes. 2014. Up to 15% of occurrences of perforation are related to diverticular illness.
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