nursing care plan for gastric perforation nursing care plan for gastric perforation

Assess the patients neurological status, taking into account any changes in consciousness or newly developed confusion. (n.d.). The nurse can also provide non-pharmacologic pain management interventions such as relaxation techniques, guided imagery, and appropriate diversional activities to promote distraction and decrease pain. Hinkle, J. L., & Cheever, K. H. (2018). The patient will demonstrate employment of relaxation skills and other methods to encourage comfort. 2023 Nurseslabs | Ut in Omnibus Glorificetur Deus! Without prompt treatment, gastrointestinal or bowel perforation can cause: Internal bleeding and significant blood loss. 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. Her nursing career has brought her through a variety of specializations, including medical-surgical, emergency, outpatient, oncology, and long-term care. This process is called digestion and metabolism. Characterize the pain according to onset, quality (dull, sharp, constant), location, and radiation. Encourage the patient to use abdominal splints.Splinting the abdomen can help reduce abdominal pressure before and after surgery when moving. The nurse can interview the client and review the health history to determine the risk factors and bleeding history of the client. This reflects nutrient requirements, condition, and organ function. NURSING CARE PLANS: Diagnoses, Interventions, and Outcomes (8th ed.). What are the common causes of bowel perforation? The most common causes of acute intestinal obstruction include adhesions, neoplasms, and herniation (). Nursing Care Plans Related to Gastrointestinal Bleed Early signs of septicemia include warm, flushed, and dry skin. Immediate medical care must be provided to patients with bowel perforation to prevent complications. In some cases, a temporary colostomy may be required to allow the bowel to heal. Provide comfort measures and non-pharmacologic pain management.The nurse can provide comfort measures such as frequent positioning, back rubs, and pillow support. Stopping the source of gastrointestinal bleeding will also control the fluid volume deficiency. Maintenance of nutritional requirements. This encourages the use of nutrients and a favorable nitrogen balance in individuals who are unable to digest nutrients normally. Give regular oral care. B. Esophagus. 3. Peptic ulcers occur with the most frequency in those between the ages of: A. 2. Nurses Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. Assess the patients level of pain and pain characteristics.Patients typically describe a worsening of abdominal pain and distention with bowel perforation. D. administering medications that decrease gastric acidity. Ineffective tissue perfusion associated with gastrointestinal bleeding can be caused by any bleeding from the mouth to the anus depending on the location. 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 complete lack of or ineffective peristalsis in the esophagus with the inability of the esophageal sphincter to relax in response to swallowing is termed achalasia. Awareness and ability to recognize and express feelings. Keep NPO and consider a nasogastric tube.The patient should be kept NPO and may require nasogastric decompression. Other Possible Nursing Care Plans. Diarrhea is often accompanied by urgency, anal discomfort, and incontinence. A 74-year-old male had a Foley catheter being used as a gastrostomy tube. 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. This care plan for gastroenteritis focuses on the initial management in a non-acute care setting. 1.The client diagnosed with a gastric ulcer, pain usually occurs 30 to 60 minutes after eating, but not at night. Learn how your comment data is processed. Changes in BP, pulse, and respiratory rate. Nursing Diagnosis: Ineffective Tissue Perfusion. The most common cause of this disease is infection obtained from consuming food or water. Likewise, the continuous release of fluids may cause dehydration. Pain occurs 1-3 hours after meals. Viral gastroenteritis also called stomach flu is a very contagious form of this disease. The nurse must closely monitor the wound and perform dressing changes as instructed. Risk for Imbalanced Nutrition: Less Than Body Requirements, Nursing Diagnosis: Risk for Imbalanced Nutrition: Less Than Body Requirements related to metabolic abnormalities (increased metabolic needs) and intestinal dysfunction secondary to bowel perforation. It is important to identify risk factors as it may influence the choice of medical intervention. Assess laboratory values.Alterations in laboratory values like white blood count can indicate infection. 2. Evaluate the pattern of defecation.The defecation pattern will promote immediate treatment. Disclosure: Included below are affiliate links from Amazon at no additional cost from you. This guide covers everything from pre-operative preparation to post-operative management. This demonstrates changes in stomach or intestinal distension and/or ascites buildup quantitatively. Place the patient in the recumbent position with the legselevated to prevent hypotension, or place the patient onthe left side to prevent. Assess what patient wants to know about the disease, andevaluate level of anxiety; encourage patient to expressfears openly and without criticism. Get a better understanding of this condition and how to provide the best care for patients. Treatment of this condition depends on its cause. Ileus is the term for the absence of peristaltic activity in the lower gastrointestinal tract. This prevents weariness and improves wellbeing. She received her RN license in 1997. A peptic ulcer may be referred to as a gastric, duodenal, or esophageal ulcer, depending on its location. 4. To prevent the occurrence of dehydration. Assist the healthcare provider in treating underlying issues.Collaboration with the healthcare provider is necessary to determine the root cause of decreased fluid volume and bleeding. Learning style, identified needs, presence of learning blocks. Evaluate the patients support system.Patients who undergo serious abdominal surgery will likely require support in the hospital and at discharge. Deficient Knowledge. 3. Learn effective and evidence-based nursing interventions and nursing care management strategies to improve patient outcomes. Assess the clients pain characteristics.The assessment of pain includes the location, characteristics, severity, palliative, and precipitating factors of the pain. Maintain accurate input and output measurements and correlate it with the patients daily weights. When the patient develops cyanotic, cold, and clammy skin, this can indicate septic shock from peritoneal infection. NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023The definitive guide to nursing diagnoses is reviewed and approved by NANDA International. INCIDENCE OF COMPLICATIONS. Includes: appendectomy, gastroenteritis, inflammatory bowel disease, live cirrhosis, and more. Electrolyte washout from the stomach during gastric aspiration may increase if there is an excessive use of ice chips. Determine fluid balance every 8 hours. The loss of blood can decrease oxygenation and perfusion to the tissues. Thanks for the questions I have learned something. C. Severe gnawing pain that increases in severity as the day progresses. These notes are a-mazing! Our expertly crafted plans will ensure your patients get the care they need to recover quickly. 3. Patient will be able to appear relaxed and able to sleep or rest appropriately. Anna Curran. 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. Our website services and content are for informational purposes only. Assess wound healing.Following surgical intervention, the nurse should monitor incisions for any redness, warmth, pus, swelling, or foul odor that signals an abscess or delayed wound healing. As shock becomes refractory, later symptoms include chilly, clammy, pale skin and cyanosis. To help diagnose the patients condition. Upper and lower origins of bleeding are the two main divisions of GI bleeding. 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. 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! Ackley and Ladwigs Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning CareWe love this book because of its evidence-based approach to nursing interventions. However, in the case of bowel perforation, contents of the bowel may leak out through the hole in its wall. St. Louis, MO: Elsevier. She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. 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. Main Article: 5 Peptic Ulcer Disease Nursing Care Plans The goals for the patient may include: Relief of pain. Collaborate with the interdisciplinary team in creating the plan of care.Collaboration of an interdisciplinary team improves communication and continuity of care. To establish the diagnosis of peptic ulcer, the following assessment and laboratory studies should be performed: Once the diagnosis is established, the patient is informed that the condition can be controlled. Statement # 1 Empiric treatment of pyloriis not recommended. St. Louis, MO: Elsevier. perforation of abdominal structures, laceration of vasculature, open wounds, peritoneal cavity contamination . Common causes of this disorder are recent abdominal surgeries and/or drugs that interfere with intestinal motility. Teach the patient how to change the dressing aseptically and wound care. The most common site for peptic ulcer formation is the: A. Duodenum. Recommended nursing diagnosis and nursing care plan books and resources. Individual cultural or religious restrictions and personal preferences. She found a passion in the ER and has stayed in this department for 30 years. Proton-pump inhibitors may be prescribed to curb stomach acid production. F. actors that may affect the functionality of the gastrointestinal tract include age, anxiety levels, intolerances, nutrition and ingestion, mobility or immobility, malnutrition, medications, and recent or coming surgical procedures. This can cause leakage of gastric acid or stool into the peritoneal cavity. Positioning: maintain an upright position at least 2 hours after meals. Nursing diagnoses handbook: An evidence-based guide to planning care. Administer medications as ordered: antidiarrheals, pain medications. The nurse auscultated over the stomach to confirm correct placement before administering medication. St. Louis, MO: Elsevier. Here are four (4) nursing care plans (NCP) and nursing diagnoses for Gastroenteritis: Diarrhea is a common symptom of acute gastroenteritis caused by bacterial, viral, or parasitic infections because these microorganisms can damage the lining of the digestive tract and lead to inflammation, which can cause fluid and electrolytes to leak from the body. 2. This exposes the structures within the peritoneal cavity to gastrointestinal contents. Laxatives soften stool and allow for easier defecation. St. Louis, MO: Elsevier. Discover the key nursing diagnoses for managing inflammatory bowel disease. Likewise, depending on the cause and type of the dysfunction, the treatment applied and the complications that may occur also vary. 3. Encourage patient to eat regularly spaced meals in arelaxed atmosphere; obtain regular weights and encouragedietary modications. 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. brings his wealth of experience from five years as a medical-surgical nurse to his role as a nursing instructor and writer for Nurseslabs, where he shares his expertise in nursing management, emergency care, critical care, infection control, and public health to help students and nurses become the best version of themselves and elevate the nursing profession. Patient will participate in care planning and follow-up appointments. Assess the patients understanding of the current condition.This will help determine the need to provide more information about the patients condition and the topics that need to be addressed. Prepare the patient for surgery.Bowel perforation may be treated through a laparoscopic procedure, or endoscopy, or if severe, may result in a colostomy. 1. Administer antibiotics as ordered. Advance the diet from clear liquids to soft meals. Patients experiencing a decrease in or lack of gastrointestinal motility commonly present with abdominal pain, bloating, nausea, vomiting, and constipation. If the perforation occurs acutely, there is no time for an inflammatory reaction to wall off the perforation, and the gastric contents freely enter the general . How is bowel perforation diagnosed and treated? Examine the color, clarity, and smell of drain outflow. With age, the incidence rises. The patient will verbalize an understanding of the disease process and its potential complications. Abdominal surgery recently or in the past, Trauma to the pelvis or abdomen, such as from an accident, Scar tissue formation, typically from a prior operation, in the pelvic area, Being assigned female at birth because a surgery can more readily injure the colon, Hemodynamic instability leading to hypoperfusion, Infection such as peritonitis, local abscess formation, or systemic bacteremia, Fistula formation, bowel obstruction, and hernia formation secondary to postoperative adhesions, The patient will achieve timely healing and be free of fever and purulent drainage or erythema. B. Clostridium difficile Dysfunctional gastrointestinal motility can be defined as the impairment of the digestive tract that results in ineffective gastric activity. 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. Patients with this condition are instructed to maintain a low-fat diet and avoid caffeine, alcohol, nicotine, and dairy products. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. 3. From pain and nutrition to coping strategies, explore effective interventions to improve patient outcomes. 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. Signs and symptoms include: After a physical examination, diagnostic procedures like blood tests, x-rays, abdominal CT scans, upper endoscopy, or a colonoscopy may be performed to confirm the condition. Nursing Diagnosis: Dysfunctional Gastrointestinal Motility related to inflammatory bowel disease as evidenced by frequency of stools, and abdominal pain. Fluids are needed to maintain the soft consistency of fecal mass. 1. Medications such as antacids or histamine receptor blockers may be prescribed. 5. Complications of gastrostomy tube placement may be minor (wound infection, minor bleeding) or major (necrotizing fasciitis, colocutaneous fistula). 1. Bowel perforation can occur due to a variety of reasons, including trauma, infections, inflammation, and medical procedures. Sedentary lifestyle and lack of activity contribute to constipation. The most common complication of peptic ulcer disease that occurs in 10% to 20% of patients is: A. Hemorrhage. C. Pylorus. Perforated ulcer surgery is an urgent life-saving intervention for severe ulcer-induced . Assess the clients history of bleeding or coagulation disorders.Determine the clients history of cancer, coagulation abnormalities, or previous GI bleeding to determine the clients risk of bleeding issues. In general, putting the patient in a supine position alleviates the pain. Intractable ulcer. Bowel perforation, a serious medical condition requiring emergency medical care, occurs when a hole develops in the bowel wall. Any bleeding that takes place in the gastrointestinal tract is referred to as gastrointestinal (GI) bleeding. Deteriorating mental status can be brought on by hypoxemia, hypotension, and acidosis. Use the appropriate solution to clean these sites. Lavage can be utilized to treat poorly localized or distributed inflammation as well as remove necrotic waste. Other causes include medications, food poisoning, infection, and metabolic disorders. 2. 5 Peptic Ulcer Disease Nursing Care Plans, Peptic ulcer disease occurs with the greatest frequency in people between. Nursing Diagnosis & Care Plan Acute Pain r/t Chemical burn of Gastric Mucosa Nursing Interventions - Record reports of pain including severity, location and duration. As directed, administer total parenteral nutrition (TPN) or tube feeds. Restrict intake of caffeine, milk, and dairy products. Assessment of the characteristics of the vomitus. Desired Outcome: The patient will demonstrate improved fluid balance as evidenced by stable vital signs, adequate urinary output with normal specific gravity, moist mucous membranes, prompt capillary refill, good skin turgor, and weight within normal range. Thirty minutes later, the JP [Jackson All the best with your nursing career and the little one! Beyond the neonatal period, perforation is rare and usually secondary to trauma, surgery, caustic ingestion, or peptic ulcer. C. eating meals when desired. Complications of bowel perforation may include: Diagnostic tests for bowel perforation should usually include: Treatment for bowel perforation should usually include the following: Nursing Diagnosis: Risk for Infection related to inadequate primary defenses invasive procedures, and immunosuppression secondary to bowel perforation. Elsevier, Inc. Patient will be able to demonstrate efficient fluid volume as evidenced by stable hemoglobin and hematocrit. Vomiting, diarrhea, and large volumes of gastric aspirate are signs of intestinal obstruction that need additional investigation. To reduce pressure on abdominal surgery wounds, keep the patient in a semi-Fowler position. Peptic Ulcer Nursing Care Plan 1 Nursing Diagnosis: Imbalanced Nutrition: Less than Body Requirements related to abdominal pain secondary to Peptic Ulcer Disease, as evidenced by burning stomach pain, bloating, weight loss, nausea and vomiting, loss of appetite, heartburn We review these signs in the light of several recent instances of delayed recognition of intestinal perforations, one of which is described here. This usually requires admittance to an acute care hospital with consultation from a gastroenterologist and a surgeon. As an outpatient department nurse, she has honed her skills in delivering health education to her patients, making her a valuable resource and study guide writer for aspiring student nurses. Good content you are having on this page loved to be a member of this page keep up the good work guyz, you are doing a great job for awareness. NurseTogether.com does not provide medical advice, diagnosis, or treatment. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance. GI bleeding is not an illness in and of itself, but rather a sign of an underlying condition. 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). 3rd Edition. 1. Provide comforting techniques such as massages and deep breathing. 4. Saunders comprehensive review for the NCLEX-RN examination. 1. The treatment is symptomatic, although cases of bacterial and parasitic infections require antibiotic therapy. Eat meals at least 2 hours before bedtime or lying down to allow the stomach to fully empty. Anna Curran. 1. Administer fluids, blood, and electrolytes as prescribed.The goal of fluid resuscitation is to improve tissue perfusion and stabilize hemodynamics. The client will pass soft, formed stool no more than 3 x a day. Feeling of emptiness that precedes meals from 1 to 3 hours. Peptic ulcer disease may occur in both genders and in all ages. To determine causative organisms and provide appropriate medications. (2020). She earned her BSN at Western Governors University. Patient will be able to verbalize relief or control of pain. DiGregorio, A. M., & Alvey, H. (2020, August 24). muscle spasms, gastric mucosal irritation, presence of invasive lines: verbalization of pain, facial grimacing, changes in vital signs, guarding: . This helps determine the degree of fluid deficiency, the efficacy of fluid replacement therapy, and the responsiveness to drugs. 3. To stop ongoing diarrhea and minimize pain experience. The nurse includes that the most common cause of peptic ulcers is: 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. Administer antiemetics or antipyretics as indicated. Administer fluids and electrolytes as ordered. Invasive procedure or surgical intervention, Leakage of bowel contents into the peritoneum. Patient will verbalize understanding of the condition, its complications, and the treatment regimen. Assess neuro status including changes in level of consciousness or new onset confusion. This provides information about organ function and hydration.