VII.

NCP AND CASE STUDY

assessment Nursing diagnosis inference planning intervention rationale Evaluation

Subjective cues: Fluid Volume, Peptic ulcers After 30 mins of Note Helpful in After effective
deficient(isotonic) nursing intervention
r/t to Active fluid the patient will: characteristics determining nursing intervention
volume  Learn the of vomitus or cause of gastric the patient was able
loss(hemorrhage) Gastric disease drainage distress to:
Objective cues: process
 Decreased erosion  Demonstrate
urine output Changes in Bp improved
 UO- 50 ml After an effective Mon itor V/S and pulse may fluid balance
 Restless nursing intervention
Epigastric be used for as evidence
 Delayed the patient will:
capillary refill mucosal  Demonstrate rough estimate by
 Weight loss tears (Mallory- improved fluid of blood loss individually
balance as
Weiss evidence by adequate
syndrome) individually Provides urinary
adequate guidelines for output with
urinary output
with normal Monitor I and fluid normal
Hematemesis specific O and replacement specific
gravity, stable correlate gravity,
V/S, moist
mucous, good weight stable V/S,
skin turgor, changes. moist
Fluid volume prompt Measure mucous,
capillary refill.
deficient blood/ fluid good skin
losses via Potential exits turgor,
emesis. for prompt
Gastric suction overtransfusion capillary
of fluids, esp. refill.
Keep accurate when volume
record of expanders are
subtotals of given before
solution/ blood
blood transfusion
products
during Activity/
replacement vomiting
therapy. increases intra
abdominal
Maintain bed pressure and can
rest; prevent predispose to
vomiting and further bleeding
straining at
stool
More easily
digested and
reduce risk of
added irritation
to inflamed
tissues. Caffeine
Provide clear/ and carbonated
band fluids beverages
when intake is stimulate HCL
resumed. production,
Avoid possibly
caffeinated potentiating
and rebleeding
carbonated
beverages
Name classification action indication contraindication Adverse effect Nursing
consideration
Omeprazole Proton pump Gastric acid pump Tx of active With Headache, Administer
inhibitor inhibitor.blocks duodenal ulcer hypersensitivity dizziness, before meals.
the final acid Tx of active to omeprazole diarrhea, nausea Administer
production benign gastric Use catiously and vomiting antacid with if
ulcer with pregnancy needed.
and lactating

Losartan Anti hypertensive Blocks the Tx of HPN With Headache, Administer

vasoconstriction Tx of diabetic hypersensitivity dizziness, without regards
effect of rennin- nephropathy to losartan, hypotension, of meal
angiotensin. Reduction of the pregnancy, abdominal pain, Monitor BP
risk of CVA lactation nausea and
Use catiously vomiting
with hepatic or
renal impairment