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NURSING MANAGEMENT NURSING CARE PLAN

NCP SUBMITTED BY: Dana P. Castro


NURSING CARE PLAN CUES NURSING DIAGNOS IS PLANNING NURSING INTERVENTION RATIONALE

PAGE 1 TO 3 - NCP

EVALUATION

SUBJECTIVE: Danay masakit pa hiya kun nadudu-on pero diri na gud duru parehas han una nga adlaw nga guin kanhi ak ha ospital. as verbalized by the client. OBJECTIVE: Pain Characteristics Location: near the midline in the epigastrium near the xiphoid Onset: DU- 2-3hr after meals or in the middle of the night -Duration: Varies depending on the immediate management of pain(ingestion of food relieves pain) -Description: burning, gnawing or cramplike -Quality: moderate or depending on the severity of the ulceration -Frequency: intermittent Pain Scale 5/10 Expressive Behavior: irritability discomfort

Acute pain related to the effect of increased gastric acid secretion leading to ulceration on damaged tissue as manifested by the 7 parameters of pain.

Short term: After 1530mins of nursing interventions, client will verbalized/ demonstrate lessened sensation of pain Long term: After 3days of nursing interventions, client will prevent the reoccurrence of pain.

Independent: 1. Build rapport to the client. Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, severity (0 to 10 or faces scale), and precipitating/ aggravating factors 3. Encourage activities that promote rest and relaxation avoidance of strenuous physical activity arrange the environment, such as, dimly & quiet environment massage the abdominal area Teach diversional techniques for stress reduction and pain relief such as deep breathing exercises, watching tv, listening to mellow music Place client in a supine or semi-fowlers position Explain the relationship between hydrochloric acid secretion and onset of pain Explain the risks of nonsteroidal antiinflammatory drugs (NSAIDS) (e.g. Motrin, Aleve, Advil) 2.

To gain trust and cooperation for the effectiveness of the regimen. Obtain a baseline data and determine or rule out worsening of underlying condition/ development of complications Relaxation of muscles decreases peristalsis and decreases gastric pain

The client will report improvement/ lessened sensation of pain as evidenced by (-)facial grimace, (-)irritability, feeling of comfort and stable vs The client prevented the reoccurrence of pain as evidenced by improvement of lifestyle, modification of diet and effective treatment regimen leading to healing of gastric or mucosal injury

The relationship between stress and peptic ulcer disease is based on the higher incidence of peptic ulcers in those with chronic anxiety Promote relaxation of the abdominal muscle Hydrochloric acid (HCl) presumably is an important variable in the appearance of peptic ulcer disease, control of HCl secretion is considered an essential aim of treatment NSAIDS cause superficial irritation of the gastric mucosa and inhibit the production of prostaglandins that protect gastric mucosa Avoidance of irritating substances can help to prevent the pain response Gastric acid secretion may be

Help the client to identify irritating Substances (e.g., fried foods, spicy foods, coffee, milk, cola)(stimulates acid secretion) Encourage the client to avoid intake of

restlessness

caffeine-containing and alcohol beverages

stimulated by caffeine ingestion. Alcohol can cause gastritis Smoking decreases pancreatic secretion of bicarbonate; this increases duodenal acidity. Tobacco delays the healing of gastric duodenal ulcers and increases their frequency Contrary to popular belief, certain dietary restrictions do not reduce hyperacidity. In individual intolerances first must be identified and used as a basis for restrictions. Avoidance of eating prior to bedtime may reduce nocturnal acid levels by eliminating the postprandial stimulus to acid secretion. During the day, regular amounts of food particles in the stomach help to neutralize the acidity of gastric secretions

Encourage the client to avoid smoking

Advise the client to eat regularly and to avoid bedtime snacks

Dependent: Administer antacids, anticholinergics, sucralfate, and H2 blockers as directed Collaborative: Work with the dietician to learn the modification of diet often requires a bland, nonirritating, low- fiber diet