nursing care plan for gastric perforation

She received her RN license in 1997. 2. Looking for the ultimate guide to Gastroenteritis Nursing Care Plans? She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. St. Louis, MO: Elsevier. Thank you Marianne! In: StatPearls [Internet]. This restores the electrolyte balance and circulation volume. In: StatPearls [Internet]. Nursing Diagnosis: Dysfunctional Gastrointestinal Motility related to limited fluid intake and sedentary lifestyle as evidenced by infrequent passage of stool, straining upon defecation, passage of dry, hard stool. When intake is restarted, the risk of stomach irritation is reduced by a careful diet progression. These complications include hemorrhage(cool skin. Remove unpleasant sights and odors from the environment. Our expertly crafted plans will ensure your patients get the care they need to recover quickly. Assess coping mechanisms of the patient.Coping mechanisms assist the patient in enduring, minimizing, and managing stressful circumstances. Emphasize the value of medical follow-up. Prepare for endoscopy or surgery.An endoscopy procedure may be necessary to determine the location and cause of GI bleeding. It is important to provide proper patient education about the condition, prognosis, treatment options, and complications to ensure adherence with the treatment regimen. A 24 day old preterm infant was referred to our . Medications such as antacids or histamine receptor blockers may be prescribed. This reduces guarding and muscle tension, which might reduce movement-related pain. Likewise, the continuous release of fluids may cause dehydration. Measure the patients abdominal circumference and be mindful of any trends. To help diagnose the patients condition. Continuously monitor ECG fir dysrhythmias resulting from electrolyte disturbances. Evaluate the pattern of defecation.The defecation pattern will promote immediate treatment. waw..You did a great work. It is important to identify risk factors as it may influence the choice of medical intervention. Encourage to increase physical activity and exercise as tolerated. C. Perforation. 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. Use the appropriate solution to clean these sites. D. Combination of all of the above. Nursing Care Plan for Bowel Perforation 1 Risk for Infection Nursing Diagnosis: Risk for Infection related to inadequate primary defenses invasive procedures, and immunosuppression secondary to bowel perforation Desired Outcomes : The patient will achieve timely healing and be free of fever and purulent drainage or erythema 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. Primary Nursing Diagnosis Pain (acute) related to gastric erosion Therapeutic Intervention / Medical Management The only successful treatment of gastric cancer is gastric resection, surgical removal of part of the stomach with involved lymph nodes; postoperative staging is done and further treatment may be necessary. St. Louis, MO: Elsevier. Colloids (plasma, blood) increase the osmotic pressure gradient, which aids in the movement of water back into the intravascular compartment. Reviewed: July 11, 2022. Administer pharmacologic pain management as ordered.Because it doesnt induce side effects like stomach pain and bleeding, acetaminophen is typically seen as being safer than other nonopioid pain medicines. Educate the client about perianal care after each bowel movement.The anal area should be gently cleaned properly after a bowel movement to prevent skin irritation and transmission of microorganisms. 2. Clients description of response to pain. Monitor for signs and symptoms of infection, such as fever and elevated heart rate. This includes measurements of all intake (oral and IV) as well as losses through vomiting, urine, and bloody stools. Other causes include medications, food poisoning, infection, and metabolic disorders. A guide to nursing diagnosis for pancreatitis, including the different types of nursing care plans, symptoms, causes, and treatments. As directed, administer total parenteral nutrition (TPN) or tube feeds. Explain that smoking may interfere with ulcer healing;refer patient to programs to assist with smokingcessation. Due to the regurgitation of food, a common complication is aspiration pneumonia. The nurse anticipates that the assessment will reveal which finding? Thanks for the questions I have learned something. If gastroenteritis involves the large intestine, the colon is not able to absorb water and the clients stool is very watery. Discover the key nursing diagnoses for managing inflammatory bowel disease. To replace losses and improve gastrointestinal function. 3. Review and Administer prescribed medications.Examine the clients prescription, over-the-counter (OTC), herbal, and nutritional supplements to find any substances that might affect fluid and electrolyte balance or may be a cause of GI bleeding. 1. Peptic ulcers occur mainly in the gastroduodenal mucosa. The esophagus, stomach, small and large intestine (colon), rectum, and anus are all parts of the GI tract. Lavage can be utilized to treat poorly localized or distributed inflammation as well as remove necrotic waste. Ileus is self-limiting and is usually resolved within 1 to 3 days. Reducing the metabolic rate and intestinal irritation caused by circulating or local toxins promotes healing and helps to relieve pain. Patients presenting with abdominal pain and . Complications of gastrostomy tube placement may be minor (wound infection, minor bleeding) or major (necrotizing fasciitis, colocutaneous fistula). In addition to the typical symptoms of a bowel perforation, symptoms of peritonitis might include: The underlying causes of bowel perforation can be categorized based on their anatomic location, however many etiologies are overlapping, and these may include: Bowel perforation can also be caused by medical procedures involving the abdomen which may include: Bowel perforation in children is most likely to occur after abdominal trauma. Nursing Interventions Nursing interventions for the patient may include: Patient will be able to maintain adequate fluid volume as evidenced by stable vital signs, balanced intake and output, and capillary refill <3 seconds. Complications of constipation include impaction, hemorrhoids, and megacolon. Gastrointestinal perforation is a hole in the wall of the stomach, small intestine, or large bowel. St. Louis, MO: Elsevier. 2. Beyond the neonatal period, perforation is rare and usually secondary to trauma, surgery, caustic ingestion, or peptic ulcer. 4. 4. The patient will verbalize an understanding of pharmacological intervention and therapeutic needs. Bowel perforation results from insult or injury to the mucosa of the bowel wall resulting from a violation of the closed system. 3. This reflects nutrient requirements, condition, and organ function. For the third spacing of fluid, take measurements from the following: stomach suction, drains, dressings, Hemovacs, diaphoresis, and abdominal circumference. Excess Fluid Volume Nursing Diagnosis and Nursing Care Plan, Pulmonary Embolism Nursing Diagnosis and Nursing Care Plan. Patient Assessment Assess tissue perfusion. Anna Curran. Administer prescribed medications.Give prescribed prophylactic medications, such as antiemetics, anticholinergics, proton pump inhibitors, antihistamines, and antibiotics. 1 - 4, 6 Adhesions resulting from prior abdominal surgery are the predominant cause of . 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. B. Esophagus. Antipyretics lessen the discomfort brought on by a fever. Learn more about the nursing care management of patients with peptic ulcer disease in this study guide. Common causes of this disorder are recent abdominal surgeries and/or drugs that interfere with intestinal motility. 3. Nursing Diagnosis: Dysfunctional Gastrointestinal Motility related to recent surgical procedure as evidenced by difficulty passing stool, hypoactive bowel sounds. The nurse can ensure the patient is type and cross-matched to prepare for blood transfusions. 5. Common causes include bowel obstruction, perforated peptic ulcers, inflammatory bowel disease, and colon cancer. Maintain accurate input and output measurements and correlate it with the patients daily weights. This prevents needless muscle stress and intra-abdominal pressure buildup. Dysfunctional gastrointestinal motility can be defined as the impairment of the digestive tract that results in ineffective gastric activity. Reduced renal perfusion, circulating toxins, and the effects of antibiotics all contribute to the development of oliguria. 15 and 25 years. Choices A, B, and D are proper interventions in providing pain control. When the bowel becomes perforated, stool and other gastric contents may spill into the abdomen and the peritoneum, causing peritonitis and sepsis. Reduce interruptions and group tasks to allow for a quiet, restful environment. Irregular mealtimes may cause constipation. To stop ongoing diarrhea and minimize pain experience. The PEG site was leaking gastric contents. Characterize the pain according to onset, quality (dull, sharp, constant), location, and radiation. 7 Gastroesophageal Reflux Disease (GERD) Nursing Care Plans, 5 Peptic Ulcer Disease Nursing Care Plans, 7 Inflammatory Bowel Disease (IBD) Nursing Care Plans. The ligament of Treitz sometimes referred to as the suspensory ligament of the duodenum, is the anatomical marker that delineates the upper and lower bleeding. The nurse can monitor the vital signs of the patient, especially alterations in the blood pressure and pulse rate which may indicate the presence of bleeding. DiGregorio, A. M., & Alvey, H. (2020, August 24). Dress surgical wounds aseptically.Surgical wounds can increase the risk of infection due to compromised skin or tissues. Changes in BP, pulse, and respiratory rate. Peristalsis may be increased, decreased, or may even be absent. Although not unusual, changes in location or intensity could signal developing complications. Desired Outcome: The patient will pass stool within 48 hours post-appendectomy. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. The abdomen may also feel rigid and stick outward farther than usual. Proton-pump inhibitors may be prescribed to curb stomach acid production. C. 40 and 60 years. In addition, the nursing care plan should focus on educating the patient on proper hygiene and food handling practices to prevent future episodes of gastroenteritis. Observe and assess the patients level of pain on a scale of 0-10. 1. To reduce pressure on abdominal surgery wounds, keep the patient in a semi-Fowler position. Discover everything you need to know in our comprehensive guide. This prevents weariness and improves wellbeing. It is relatively uncommon in women of childbearing age, but it has been observed in children and even in infants. Peptic ulcers are more likely to occur in the duodenum. Monitor intake and output.To track and record trends, the nurse must maintain precise intake and output (I&O) documentation. Her experience spans almost 30 years in nursing, starting as an LVN in 1993. These will lessen fluid loss and neutralize stomach acid hopefully preventing further irritation of the GI mucosa. Peritonitis, inflammation of the inner abdominal wall lining. Surgery for intestinal perforation is contraindicated in the presence of general contraindications to anesthesia and major surgery, such as severe heart failure, respiratory failure, or. Pain is typically very bad, and narcotic painkillers may be necessary. Updated October 6, 2018. The nursing goals of a client with a peptic ulcer disease include reducing or eliminating contributing factors, promoting comfort measures, promoting optimal nutrition, decreasing anxiety with increased knowledge of disease, management, and prevention of ulcer recurrence and preventing complications. The management of the patient with a peptic ulcer is as follows:. NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023The definitive guide to nursing diagnoses is reviewed and approved by NANDA International. NURSING CARE PLANS: Diagnoses, Interventions, and Outcomes (8th ed.). Assist the patient in understanding the condition and factors that help or aggravate it. Deteriorating mental status can be brought on by hypoxemia, hypotension, and acidosis. This article looks at . Its important to also assess the exact location of abdominal pain. Desired Outcome: The patient will maintain passage of soft, formed stool at a regular frequency. As a result, organs enclosed within the peritoneal cavity are exposed to digestive fluids, forming a hole through the wall of the organ. Imbalanced Nutrition: Less Than Body Requirements. Encourage to increase oral fluid intake if not contraindicated. From pain and nutrition to coping strategies, explore effective interventions to improve patient outcomes. This provides baseline knowledge to allow the patient to make educated decisions. 1. The patient will demonstrate employment of relaxation skills and other methods to encourage comfort. Food is commonly regurgitated as it does not pass to the stomach, leading to chest pain, heartburn, nausea, and vomiting. Perforated ulcer surgery is an urgent life-saving intervention for severe ulcer-induced . Peptic ulcer disease may occur in both genders and in all ages. Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). Encourage patient to eat regular meals in a. A characteristic associated with peptic ulcer pain is a: A. This decreases vomiting and nausea, which can worsen pain and increase intra-abdominal pressure. This condition can be caused by injury, trauma, or an underlying health condition, including: It is vital to seek medical care when clinical signs of bowel perforation occur. This usually requires admittance to an acute care hospital with consultation from a gastroenterologist and a surgeon. D. 60 and 80 years. Frequently change the patients position. Certain drugs can slow down peristalsis and contribute to constipation, i.e. 1. Nursing Care Plans Related to Gastrointestinal Bleed Patients experiencing a decrease in or lack of gastrointestinal motility commonly present with abdominal pain, bloating, nausea, vomiting, and constipation. Feeling of emptiness that precedes meals from 1 to 3 hours. Educate the patient to avoid triggers. Assess vital signs.Recognize persistent hypotension, which may lead to abdominal organ hypoperfusion. Upper and lower origins of bleeding are the two main divisions of GI bleeding. Bowel perforation can increase morbidity and mortality even when treated properly because of post-repair problems such as adhesions and fistula formation. 2. The patient will accurately perform necessary procedures and explain reasons for these actions. Alert patient to signs and symptoms of complications tobe reported. Here are five (5) nursing care plans (NCP) for peptic ulcer disease: Hospitalization may be needed for clients who experience severe dehydration as a result of the vomiting and diarrhea. Nursing interventions for the patient may include: If perforation and penetration are concerns: The patient should be taught self-care before discharge. Note and report symptoms of perforation (sudden abdominal pain, referred pain to shoulders, vomiting andcollapse, extremely tender and rigid abdomen,hypotension and tachycardia, or other signs of shock). Positioning: maintain an upright position at least 2 hours after meals. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process and help nursing students pass the NCLEX exams. Antacids without aspirin and proton pump inhibitors may alleviate heartburn. Discuss with the patient the dosage, frequency, and potential negative effects of the medications. Buy on Amazon, Silvestri, L. A. Deficient fluid volume associated with gastrointestinal bleeding can be caused by decreased blood volume due to blood loss. Encourage the client to eat foods rich in potassium.When a client experience diarrhea, the stomach contents which are high in potassium get flushed out of the gastrointestinal tract into the stool and out of the body,resulting in hypokalemia. 3. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively sample clinical applications, prioritized action/interventions with rationales a documentation section, and much more! Learn effective and evidence-based nursing interventions and nursing care management strategies to improve patient outcomes. Constipation is a condition wherein there is an abnormal decrease in frequency or irregularity of defecation. Patient will be free from any signs of infection or further complications. She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. Sedentary lifestyle and lack of activity contribute to constipation. National Center for Biotechnology Information. GI bleeding is not an illness in and of itself, but rather a sign of an underlying condition. [Updated 2022 Aug 14]. In Brunner and Suddarths textbook of medical-surgical nursing (14th ed., pp. 2023 Nurseslabs | Ut in Omnibus Glorificetur Deus! There are three major causes of peptic ulcer disease: infection with H. pylori, chronic use of NSAIDs, and pathologic hypersecretory disorders (e.g., Zollinger-Ellison syndrome). Please visit our nursing test bank for more NCLEX practice questions. Antibiotics may also be prescribed to treat any infections that may be present. Management of Patients with Gastric and Duodenal Disorders. Bowel ischemia and gastrointestinal (GI) hypoperfusion can be caused by blood loss, hypovolemic or hypotensive shock, or both. Eat meals at least 2 hours before bedtime or lying down to allow the stomach to fully empty. We may earn a small commission from your purchase. Teach patient about prescribed medications, including name. This is due to a decrease in blood flow and oxygen in the gastrointestinal system. The most common cause of this disease is infection obtained from consuming food or water. 5 Peptic Ulcer Disease Nursing Care Plans, Peptic ulcer disease occurs with the greatest frequency in people between. B. 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. 11th Edition, Mariann M. Harding, RN, Ph.D., FAADN, CNE. Invasive procedure or surgical intervention, Leakage of bowel contents into the peritoneum. ulcer surgery, gastric ulcer surgery, or peptic ulcer surgery) is a procedure for treating a stomach ulcer. Diet modification: small frequent feedings, bland meals, avoidance of caffeine, spicy, citrus, dairy products, and carbonated products. 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). This helps determine the degree of fluid deficiency, the efficacy of fluid replacement therapy, and the responsiveness to drugs. Knowledge about the management and prevention of ulcer recurrence. Statement # 1 Empiric treatment of pyloriis not recommended. Assessment of relief measures to relieve the pain. Patient will be able to demonstrate efficient fluid volume as evidenced by stable hemoglobin and hematocrit. gram-negative bacteria. Nursing Diagnosis: Dysfunctional Gastrointestinal Motility related to gastroesophageal reflux disease as evidenced by nausea and vomiting, abdominal cramping, and regurgitation. The client will pass soft, formed stool no more than 3 x a day. Nursing Care Plans and Interventions 1. 3. Auscultate the bowels for irregular, absent, or hyperactive bowel sounds. Interprofessional patient problems focus familiarizes you with how to speak to patients. Surgery may be necessary if bleeding is severe and tests cant visualize the source. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking. - Identify and limit foods that aggravate condition or cause increased discomfort. The patient will verbalize an understanding of the disease process and its potential complications. Around 2% of colonoscopies are reported to result in perforations generally, with greater rates during the procedure necessitating therapeutic measures. The type of pain presented may assist in narrowing down the type of IBD the patient has. NurseTogether.com does not provide medical advice, diagnosis, or treatment. This lowers the danger of contamination and gives the chance to assess the healing process. Gastrointestinal bleeding StatPearls NCBI bookshelf. Over time, partial erosion might progress to full-thickness tears, or a particular lesion can prompt a spontaneous rupture. Buy on Amazon, Silvestri, L. A. The treatment is symptomatic, although cases of bacterial and parasitic infections require antibiotic therapy. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. Individual cultural or religious restrictions and personal preferences. Take note if the patient is experiencing vomiting or diarrhea. Recommend patient to maintain a normal weight, or to lose weight if needed. Saunders comprehensive review for the NCLEX-RN examination. Helicobacter pylori is considered to be the major cause of ulcer formation. 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. 5. Upon entry of food by mouth, it is transported to the stomach and eventually the small and large intestines by wave-like contractions of the gastrointestinal muscles known as peristalsis. its really Help. She has worked in Medical-Surgical, Telemetry, ICU and the ER. Stopping the source of gastrointestinal bleeding will also control the fluid volume deficiency. If left untreated, it can result in internal bleeding, peritonitis, permanent damage to the intestines, sepsis, and death. Surgically, esophagomyotomy is done to relieve the lower esophageal stricture. opioids, antacids, antidepressants, anesthetics, etc. 1. Administer antidiarrheal medications as prescribed.Bismuth salts, kaolin, and pectin which are adsorbent antidiarrheals are commonly used for treating the diarrhea of gastroenteritis. She received her RN license in 1997. Provide instructions to a dependable support person. There are various etiologies of constipation, including but not limited to certain medications, rectal or anal disorders, obstruction, neuromuscular conditions, irritable bowel syndrome, immobility, and others. Assessment of the characteristics of the vomitus. Assess the clients pain characteristics.The assessment of pain includes the location, characteristics, severity, palliative, and precipitating factors of the pain. Evaluate the patients support system.Patients who undergo serious abdominal surgery will likely require support in the hospital and at discharge.

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