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Student Nurses Community

NURSING CARE PLAN Upper Gastrointestinal Bleeding


ASSESSMENT

SUBJECTIVE:
Napakasakit ng
tiyan ko (Im
having severe
stomach pain) as
verbalized by the
patient.

OBJECTIVE:

Abdominal
guarding
Rigid body
posture
Facial
grimacing
V/S taken as
follows
T: 37.3C
P: 89
R: 19
BP: 110/ 80

DIAGNOSIS

Acute or
chronic pain
maybe related
to chemical
burn of gastric
mucosa, oral
cavity and
physical
response such
as flex muscle
spasm in the
stomach wall.

INFERENCE

PLANNING

Acid, pepsin, and


helicobacter
infection play an
important role in
the development
of gastric ulcers.
The gastric
mucosal barrier
overlies the
epithelium. The
secretion of
mucus and
bicarbonate
provides a first
line defense in
maintaining a
near-normal pH
on the gastric
epithelium and
protects the
mucosal barrier
against acid.
Gastromucosal
prostaglandins
increase the
barriers
resistance to
ulceration. The
integrity of the
barrier is
enhanced by the
rich blood supply
of the mucosa of
the stomach and
duodenum.

After 4 hours of
nursing
interventions, the
Patient verbalize
relief of pain and
demonstrate
relaxed body
posture and be
able to sleep or
rest properly.

INTERVENTION

Independent
Note reports of
pain, including
location, duration,
and intensity (0-10
scale).

Review factors that


aggravate or
alleviate pain.

Note nonverbal
pain cues.

Provide small
frequent meals.

Identify and limit


foods that create
discomfort.

Assist with active


and passive range
of motion
exercises.

Provide frequent
oral care and
comfort measures
including back rub
and position
change.

RATIONALE

EVALUATION

Pain is not always


present, should
be compared with
patients previous
pain symptoms.
The comparison
may assist in
diagnosis of
etiology of
bleeding and
development of
complications.

After 4 hours of
nursing
interventions, the
Patient was able to
verbalize relief of
pain and
demonstrate relaxed
body posture and be
able to sleep or rest
properly.

Helpful in
establishing
diagnosis and
treatment needs.
Non-verbal cues
may be both
physiological and
psychological and
may be use in
conjunction with
verbal cues to
evaluate extent
and severity of
the problem.
Food has an acidneutralizing effect
and dilutes the
gastric contents.

Student Nurses Community

Collaborative

Provide and
implement dietary
modifications.

Use regular than


skim milk, if milk is
allowed.

Administer
medications as
indicated such as
analgesics.

Small meals
prevent distention
and the release of
gastrin.
Specific foods that
cause distress
vary among
individuals. Spicy
foods, alcohol,
and coffee can
precipitate
dyspepsia.
Reduces joint
stiffness,
minimizing pain
and discomfort.
Halitosis from
stagnant oral
secretions is
unappetizing and
can aggravate
nausea.
Client may receive
nothing by mouth
initially. When
oral intake is
allowed, food
choices depend
on the diagnosis
and etiology of
the bleeding.

Student Nurses Community

Fat in regular milk


may decreases
gastric
secretions. The
calcium and
protein content
especially in skim
milk increases
secretions.
Helps relive acute
or severe pain.