As an Amazon Associate I earn from qualifying purchases. Prepare for endoscopy or surgery.An endoscopy procedure may be necessary to determine the location and cause of GI bleeding. 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 Evaluate the patients abdomen periodically for softening, the resumption of regular bowel noises, and the passing of flatus. Here are four (4) nursing care plans (NCP) and nursing diagnoses for Gastroenteritis: Diarrhea. In this disorder, the esophagus gradually widens as food regularly accumulates in the esophagus. Restrict intake of caffeine, milk, and dairy products. Plan rest periods and create a conducive environment for sleeping and resting.Rest increases coping abilities by reducing fatigue and conserving energy. Nursing Diagnosis: Acute Pain related to tissue trauma, chemical irritation of the parietal peritoneum, and abdominal distension secondary to bowel perforation as evidenced by muscle guarding, rebound tenderness, verbalization of pain, distraction behavior, facial mask of pain, and autonomic or emotional responses (anxiety). Use the appropriate solution to clean these sites. The nurse is conducting a community education program on peptic ulcer disease prevention. Remove unpleasant sights and odors from the environment. Lavage can be utilized to treat poorly localized or distributed inflammation as well as remove necrotic waste. Clients description of response to pain. Its important to also assess the exact location of abdominal pain. Assess the patient for intake of contaminated food or water or undercooked or raw meals. A characteristic associated with peptic ulcer pain is a: A. Administer antidiarrheal medications as prescribed.Bismuth salts, kaolin, and pectin which are adsorbent antidiarrheals are commonly used for treating the diarrhea of gastroenteritis. Please visit our nursing test bank for more NCLEX practice questions. Get an in-depth understanding of Cholecystectomy Nursing Care Plans and Nursing Diagnosis, including the common nursing interventions and outcomes. What are the signs and symptoms of bowel perforation? Provide comfort measures and non-pharmacologic pain management.The nurse can provide comfort measures such as frequent positioning, back rubs, and pillow support. She has worked in Medical-Surgical, Telemetry, ICU and the ER. DiGregorio, A. M., & Alvey, H. (2020, August 24). 1. Encourage patient to eat regular meals in a. (2020). Dysfunctional gastrointestinal motility can be defined as the impairment of the digestive tract that results in ineffective gastric activity. Although not unusual, changes in location or intensity could signal developing complications. Major Nursing Issues and Interventions . 5. Encourage patient to eat regularly spaced meals in arelaxed atmosphere; obtain regular weights and encouragedietary modications. Prepare the patient for what to expect with their procedure by encouraging and answering questions. Her experience spans almost 30 years in nursing, starting as an LVN in 1993. If gastroenteritis involves the large intestine, the colon is not able to absorb water and the clients stool is very watery. Medical-surgical nursing: Concepts for interprofessional collaborative care. Gastrointestinal Care Plans, Nursing Care Plans 7 Gastroesophageal Reflux Disease (GERD) Nursing Care Plans Stopping the source of gastrointestinal bleeding will also control the fluid volume deficiency. Patients with bowel perforation have a very high risk of developing an infection. This care plan for gastroenteritis focuses on the initial management in a non-acute care setting. However, common signs and symptoms include severe abdominal pain, bloating, nausea and vomiting, fever, chills, and a rapid heartbeat. Administer medications as ordered: antidiarrheals. Assess imaging and laboratory studies.Imaging studies like colonoscopy, CT scan, and x-ray can help confirm the diagnosis, locate the perforated site, and plan appropriate interventions to manage the extent of bowel perforation. It is either caused by bacteria or chemicals, can either be primary or secondary, and acute or chronic. Assessment of the characteristics of the vomitus. The perforation of an ulcer can be a life-threatening emergency requiring early detection and, often, immediate surgical intervention. Effective nursing care is essential for patients with gastrointestinal bleeding to alleviate symptoms, lower the risk of complications, and promote patient psychological well-being and prognoses. These drugs coat the intestinal wall and absorb bacterial toxins. Interact in a relaxing manner, help in identifying stressors,and explain effective coping techniques and relaxationmethods. Gastroenteritis (also known as Food Poisoning; Stomach Flu; Travelers Diarrhea ) is the inflammation of the lining of the stomach and small and large intestines. Our website services and content are for informational purposes only. document.getElementById("ak_js_1").setAttribute("value",(new Date()).getTime()); This site uses Akismet to reduce spam. Stomach ulcer surgery (a.k.a. Characterize the pain according to onset, quality (dull, sharp, constant), location, and radiation. Inform the patient about the necessity of using a pillow or other soft object to splint the surgical site in order to reduce pain when moving. She has more than 10 years of clinical and teaching experience and worked as a licensed Nursing Specialist in JCI-accredited hospitals in the Middle East. Patient will be able to demonstrate efficient fluid volume as evidenced by stable hemoglobin and hematocrit. To minimize the occurrence of signs and symptoms of GERD and avoid exacerbation of the condition. Her nursing career has led her through many different specialties including inpatient acute care, hospice, home health, case management, travel nursing, and telehealth, but her passion lies in educating through writing for other healthcare professionals and the general public. Spontaneous perforation of the stomach is an uncommon event mainly seen in the neonatal period, the first few days of life, as a cause of pneumoperitoneum. Patient will participate in care planning and follow-up appointments. This restores the electrolyte balance and circulation volume. Up to 15% of occurrences of perforation are related to diverticular illness. Other recommended site resources for this nursing care plan: More nursing care plans related to gastrointestinal disorders: document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Paul Martin R.N. Hypovolemia and reduced renal perfusion may reduce urine production, yet weight gain due to ascites accumulation or tissue edema may still occur. Healthline. 2. Patients who present with abdominal pain and distension, especially in the right historical context, must be assessed for this entity because a delayed diagnosis increases the risk of developing infections like peritonitis, which can be fatal. Other causes include medications, food poisoning, infection, and metabolic disorders. Proton-pump inhibitors may be prescribed to curb stomach acid production. Pain occurs 1-3 hours after meals. Reduced anxiety. Imbalanced Nutrition: Less Than Body Requirements. 15 and 25 years. Maintenance of nutritional requirements. Determine the patients threshold for bearable pain and give them painkillers to stay within it. https://www.ncbi.nlm.nih.gov/books/NBK537291/, https://www.msdmanuals.com/professional/gastrointestinal-disorders/gastrointestinal-bleeding/overview-of-gastrointestinal-bleeding, Atrial Fibrillation: Nursing Diagnoses, Care Plans, Assessment & Interventions, Compartment Syndrome Nursing Diagnosis & Care Plan, Patient will be able to demonstrate effective tissue perfusion as evidenced by hemoglobin and hematocrit within normal limits. Look no further! In this new version of a pioneering text, all introductory chapters have been rewritten to provide nurses with the essential information they need to comprehend assessment, its relationship to diagnosis and clinical reasoning, and the purpose and application of taxonomic organization at the bedside. Assess neuro status including changes in level of consciousness or new onset confusion. Ask the client about arecent history of drinking contaminated water, eating food inadequately cooked, and ingestion of unpasteurized dairy products:Eating contaminated foods or drinking contaminated water may predispose the client to intestinal infection. This demonstrates changes in stomach or intestinal distension and/or ascites buildup quantitatively. 2. Take note if the patient is experiencing vomiting or diarrhea. Jones MW, Kashyap S, Zabbo CP. Determine fluid balance every 8 hours. Along with oxygenation, organs require nutrients like antioxidants, vitamins, and minerals to function. 2. The patient should be kept NPO and may require nasogastric decompression. 1. When the bowel becomes perforated, stool and other gastric contents may spill into the abdomen and the peritoneum, causing peritonitis and sepsis. Discuss symptoms that require immediate medical attention.Signs and symptoms like worsening abdominal pain and discomfort, chills, fever, nausea and vomiting, and purulent drainage with edema and erythema around the surgical site must be reported, as this can indicate developing complications. 3rd Edition. Administer prescribed medications.Give prescribed prophylactic medications, such as antiemetics, anticholinergics, proton pump inhibitors, antihistamines, and antibiotics. Upper and lower origins of bleeding are the two main divisions of GI bleeding. This lessens abdominal tension and/or diaphragmatic irritation, which in turn lessens pain by facilitating fluid or wound drainage by gravity. 4. National Center for Biotechnology Information. The loss of blood can decrease oxygenation and perfusion to the tissues. NURSING CARE PLANS: Diagnoses, Interventions, and Outcomes (8th ed.). Anna Curran. The reported rates of complications following percutaneous endoscopic gastrostomy (PEG) tube placement vary from 16 to 70 percent [ 1-5 ]. The most common complication of peptic ulcer disease that occurs in 10% to 20% of patients is: A. Hemorrhage. MSD Manual Professional Edition. Encourage the patient to follow up with care.Monitoring after surgical intervention for bowel perforation is essential to avoid complications like a fistula or hernia. Deficient fluid volume associated with gastrointestinal bleeding can be caused by decreased blood volume due to blood loss. The pattern will assist the healthcare team in providing speedy, appropriate treatment and management. Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client CareIdentify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Encourage the patient to use abdominal splints.Splinting the abdomen can help reduce abdominal pressure before and after surgery when moving. Early signs of septicemia include warm, flushed, and dry skin. Gastrointestinal bleeding StatPearls NCBI bookshelf. RN, BSN, PHNClinical Nurse Instructor, Emergency Room Registered NurseCritical Care Transport NurseClinical Nurse Instructor for LVN and BSN students. 3. Encourage to increase physical activity and exercise as tolerated. Our expertly crafted plans will ensure your patients get the care they need to recover quickly. She found a passion in the ER and has stayed in this department for 30 years. Response to interventions, teaching, and actions performed. To stop ongoing diarrhea and minimize pain experience. Teach the client about the importance of hand washing after each bowel movement and before preparing food for others.Hands that are contaminated may easily spread the bacteria to utensils and surfaces used in food preparation hence hand washing after each bowel movement is the most efficient way to prevent the transmission of infection to others. Gastroesophageal reflux disease is a good example of a condition wherein motility is ineffective. The type of pain presented may assist in narrowing down the type of IBD the patient has. Bowel perforation can increase morbidity and mortality even when treated properly because of post-repair problems such as adhesions and fistula formation. These contents can range from feces from a more distal location of perforation to extremely acidic gastric contents in more proximal bowel perforation. 4. Assess coping mechanisms of the patient.Coping mechanisms assist the patient in enduring, minimizing, and managing stressful circumstances. If left untreated, it can result in internal bleeding, peritonitis, permanent damage to the intestines, sepsis, and death. Sedentary lifestyle and lack of activity contribute to constipation. Ileus is self-limiting and is usually resolved within 1 to 3 days. Bowel perforation results from insult or injury to the mucosa of the bowel wall resulting from a violation of the closed system. Assess complaints of pain, pain response, pain characteristics. 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. Patient will be able to maintain adequate fluid volume as evidenced by stable vital signs, balanced intake and output, and capillary refill <3 seconds. The nurse must closely monitor the wound and perform dressing changes as instructed. This reflects the patients state of total hydration. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Marianne leads a double life, working as a staff nurse during the day and moonlighting as a writer for Nurseslabs at night. Hafner J, Tuma F, Hoilat GJ, et al. To maintain H&H, administer blood products as necessary. This usually requires admittance to an acute care hospital with consultation from a gastroenterologist and a surgeon. Teach the patient breathing and visualization techniques and offer diversionary pursuits. Medical management includes calcium channel blockers and nitrates as they assist in decreasing esophageal pressure and improving swallowing. Pneumatic dilation may be done. Nursing Care Plan 2.21.2007 NCP Upper Gastrointestinal / Esophageal Bleeding Bleeding duodenal ulcer is the most frequent cause of massive upper gastrointestinal (GI) hemorrhage, but bleeding may also occur because of gastric ulcers, gastritis, and esophageal varices. Neonatal gastrointestinal perforation is a common condition carrying a mortality of 17-60%.1 Clinical suspicion is supported by radiological signs, which may be subtle and must be sought specifically. 2. Buy on Amazon, Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Knowledge about the management and prevention of ulcer recurrence. Symptoms of ulcer may last for a few days, weeks, months, and may disappear only to reappear, often without an identifiable cause. Colloids (plasma, blood) increase the osmotic pressure gradient, which aids in the movement of water back into the intravascular compartment. Get a better understanding of this condition and how to provide the best care for patients. 1 - 4, 6 Adhesions resulting from prior abdominal surgery are the predominant cause of . 4. St. Louis, MO: Elsevier. Nursing care plans: Diagnoses, interventions, & outcomes. Fluids are needed to maintain the soft consistency of fecal mass. Assess dietary habits, intake, and activity level. Place the patient in the recumbent position with the legselevated to prevent hypotension, or place the patient onthe left side to prevent. NurseTogether.com does not provide medical advice, diagnosis, or treatment. Likewise, the continuous release of fluids may cause dehydration. 1. C. Candida albicans The stomach showed no attachment to the abdominal wall. Buy on Amazon. The nursing care plan goals for patients with gastroenteritis include preventing dehydration by promoting adequate fluid and electrolyte intake, managing symptoms such as nausea and diarrhea, and preventing the spread of infection to others. perforation of abdominal structures, laceration of vasculature, open wounds, peritoneal cavity contamination . 3426-3452). These will lessen fluid loss and neutralize stomach acid hopefully preventing further irritation of the GI mucosa. Wolters Kluwer India Pvt. Teach patient about prescribed medications, including name. Advance the diet from clear liquids to soft meals. St. Louis, MO: Elsevier. All-in-One Nursing Care Planning Resource E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental HealthIncludes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Observe and assess the patients level of pain on a scale of 0-10. Identify the signs and symptoms that necessitates prompt medical evaluation: persistent abdominal pain and discomfort, nausea, vomiting, fever, chills, or purulent drainage, edema, or erythema around a surgical incision (if present). St. Louis, MO: Elsevier. gram-negative bacteria. Nursing Diagnosis: Dysfunctional Gastrointestinal Motility related to inflammatory bowel disease as evidenced by frequency of stools, and abdominal pain. To help diagnose the patients condition. ACCN Essentials of Critical Care Nursing. Measure the patients urine specific gravity. Assessment of relief measures to relieve the pain. (2020). It is vital to determine the source and cause of bleeding and intervene. The most common signs and symptoms noted are heartburn, and indigestion. However, in the case of bowel perforation, contents of the bowel may leak out through the hole in its wall. A 24 day old preterm infant was referred to our . Evaluate the pattern of defecation.The defecation pattern will promote immediate treatment. Gastric bypass: Also referred to as Roux-en-Y gastric bypass, gastric bypass reduces the size of your stomach.Surgeons create a small pouch using the top part of your stomach. This encourages the use of nutrients and a favorable nitrogen balance in individuals who are unable to digest nutrients normally. This provides baseline knowledge to allow the patient to make educated decisions. Management of this disorder includes temporary cessation of diet and intravenous nutrient supplementation. Over time, partial erosion might progress to full-thickness tears, or a particular lesion can prompt a spontaneous rupture.

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