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

d by the patien t. OBJECTIVE: Abdominal guarding Rigid body posture Facial grimacing V/S taken as follows

T: 37.3C P: 89 R: 19 BP: 110/ 80 Acute or chronic pain maybe related to chemical burn of gastric mucosa, oral cav ity and physical response such as flex muscle spasm in the stomach wall. After 4 hours of nursing interventions, the Patient verbalize relief of pain an d demonstrate relaxed body posture and be able to sleep or rest properly. 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. Collaborative Provide and implement dietary modifications. Use regular than skim milk, if milk is allowed. Administer medications as indicated such as analgesics.

RATIONALE: Pain is not always present, should be compared with patients previous pain sympto ms. The comparison may assist in diagnosis of etiology of bleeding and developme nt of complications. Helpful in establishing diagnosis and treatment needs. Non-verbal cues may be both physiological and psychological and may be use in co njunction with verbal cues to evaluate extent and severity of the problem. Food has an acid-neutralizing effect and dilutes the gastric contents. Small mea ls 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. Fat in regular milk may decreases gastric secretions. The calcium and protein co ntent especially in skim milk increases secretions. Helps relive acute or severe pain. After 4 hours of nursing interventions, the Patient was able to verbalize relie f of pain and demonstrate relaxed body posture and be able to sleep or rest prop erly.