Student Nurses Community

NURSING CARE PLAN Upper Gastrointestinal Bleeding ASSESSMEN SUBJECTIVE: Napakasakit ng tiyan ko (Im
having severe stomach pain) as

!IAGN"SIS %*'te or *"roni* pain &aybe relate! to *"e&i*al b'rn o, gastri* &'*osa6 oral *avity an! p"ysi*al response s'*" as ,le7 &'s*le spas& in t"e sto&a*" -all#

IN#ERENCE %*i!6 pepsin6 an! "eli*oba*ter in,e*tion play an i&portant role in t"e !evelop&ent o, gastri* 'l*ers# T"e gastri* &'*osal barrier overlies t"e epit"eli'&# T"e se*retion o, &'*'s an! bi*arbonate provi!es a ,irst line !e,ense in &aintaining a near8 nor&al p9 on t"e gastri* epit"eli'& an! prote*ts t"e &'*osal barrier against a*i!# :astro&'*osal prostaglan!ins in*rease t"e barrier;s resistan*e to 'l*eration# T"e integrity o, t"e barrier is en"an*e! by t"e ri*" bloo! s'pply o, t"e &'*osa o, t"e sto&a*" an! !'o!en'&#

PLANNING %,ter < "o'rs o, n'rsing interventions6 t"e 1atient verbali e relie, o, pain an! !e&onstrate rela7e! bo!y post're an! be able to sleep or rest properly#

IN ER$EN I"N Independent Note reports o, pain6 in*l'!ing lo*ation6 !'ration6 an! intensity (5845 s*ale)#

RA I"NALE 1ain is not al-ays present6 s"o'l! be *o&pare! -it" patient;s previo's pain 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 to eval'ate e7tent an! severity o, t"e proble&# )oo! "as an a*i!8 ne'trali ing e,,e*t an! !il'tes t"e gastri* *ontents# S&all &eals prevent !istention an! t"e release o, gastrin# Spe*i,i* ,oo!s t"at *a'se !istress vary a&ong in!ivi!'als# Spi*y ,oo!s6 al*o"ol6 an! *o,,ee *an pre*ipitate

E$ALUA I"N %,ter < "o'rs o, n'rsing interventions6 t"e 1atient -as able to verbali e relie, o, pain an! !e&onstrate rela7e! bo!y post're an! be able to sleep or rest properly#

verbali e! by t"e patient#

$BJECTIVE: %b!o&inal g'ar!ing (igi! bo!y post're )a*ial gri&a*ing V+S taken as ,ollo-s T: ./#.0C 1: 23 (: 43 B1: 445+ 25

(evie- ,a*tors t"at aggravate or alleviate 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#

Student Nurses Community

!yspepsia# (e!'*es >oint sti,,ness6 &ini&i ing pain an! !is*o&,ort# 9alitosis ,ro& stagnant oral se*retions is 'nappeti ing an! *an aggravate na'sea# Client &ay re*eive not"ing by &o't" initially# ?"en oral intake is allo-e!6 ,oo! *"oi*es !epen! on t"e !iagnosis an! etiology o, t"e blee!ing# )at in reg'lar &ilk &ay !e*reases gastri* se*retions# T"e *al*i'& an! protein *ontent espe*ially in ski& &ilk in*reases se*retions# 9elps relive a*'te or severe pain#

%ssist -it" a*tive an! passive range o, &otion e7er*ises# 1rovi!e ,re='ent oral *are an! *o&,ort &eas'res in*l'!ing ba*k r'b an! position *"ange#

Colla%orati&e 1rovi!e an! i&ple&ent !ietary &o!i,i*ations#

Use reg'lar t"an ski& &ilk6 i, &ilk is allo-e!#

%!&inister &e!i*ations as in!i*ate! s'*" as analgesi*s#