ASSESSMENT

SUBJECTIVE: Nasakit ditoy ayan ti tiyan koas verbalized by the patient

DIAGNOSIS
Acute pain r/t Hyperacidity secondary to irritation of gastric mucosa

PLANNING
After 1-2 hours of nursing intervention the patient will verbalize relief of pain. Reduce Pain Scale from 6 to 3

INTERVENTION
Independent Note reports of pain, including location, duration, intensity (0 10 scale)

RATIONALE
Pain is not always present, but if present should be compared with patients previous pain symptoms. This comparison may assist in diagnosis of etiology of bleeding and development of complications. Helpful in establishing diagnosis and treatment needs. Food has an acid neutralizing effect and dilutes the gastric contents.

EVALUATION
Goal met, patient has verbalized relief of pain. Reduced Pain Scale from 6 to 3. Demonstrated relaxed body posture and be able to sleep/rest appropriately.

OBJECTIVE: Epigastric pain Abdominal guarding Restlessness

Demonstrate relaxed body posture and be able to sleep/rest appropriately.

Review factors that aggravate or alleviate pain.

facial grimacing

pain scale of 6 out of 10

Identify and limit foods that create discomfort such as spicy or carbonated drink. Encourage small, frequent meals

Encourage patient to assume position of comfort.

Small meals prevent distension and the release of gastrin Reduces abdominal tension and promotes sense of control.

COLLABORATIVE Provide and implement prescribed dietary modifications. Patient may receive nothing by mouth (NPO) initially. When oral intake is allowed, food choices depend on the diagnosis May be narcotic of choice to relieve acute/severe pain and reduce peristaltic activity. Note: Meperidine (Demerol) has been associated with increased incidence of nausea/vomiting Decreases gastric acidity by absorption or by chemical neutralization. Evaluate choice of antacid in regard to total health picture, e.g., sodium restriction May be given at

Administer medications as indicated Analgesics, e.g., morphine sulfate

Antacids

Anticholinergics, e.g., belladonna,

atropine bedtime to decrease gastric motility, suppress acid production, delay gastric emptying, and alleviate nocturnal pain associated with gastric ulcer.

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION