Eat meals at least 2 hours before bedtime or lying down to allow the stomach to fully empty. 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. Prepare and assist in surgery.Surgery is indicated in patients with bowel perforation to help repair the perforated area and prevent complications like peritonitis and sepsis. Common causes of diarrhea are irritable bowel syndrome, inflammatory bowel disease, and lactose intolerance. 2014. Management of this disorder includes temporary cessation of diet and intravenous nutrient supplementation. F A Davis Company. 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. 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. Pain is typically very bad, and narcotic painkillers may be necessary. document.getElementById("ak_js_1").setAttribute("value",(new Date()).getTime()); This site uses Akismet to reduce spam. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking. Desired Outcome: The patient will practice appropriate behaviors to assist with resolution of condition. Gastroesophageal reflux disease is a good example of a condition wherein motility is ineffective. The patient will verbalize an understanding of pharmacological intervention and therapeutic needs. Nursing diagnoses handbook: An evidence-based guide to planning care. Since analgesics can conceal symptoms and indications, they may be withheld throughout the first diagnostic process. Get answers to commonly nursing interventions and nursing management for effective treatment. Ineffective tissue perfusion associated with gastrointestinal bleeding can be caused by any bleeding from the mouth to the anus depending on the location. Certain food products exacerbate signs and symptoms of GERD. Monitor laboratory values (hemoglobin and hematocrit). Include also measured losses. Looking for the ultimate guide to Gastroenteritis Nursing Care Plans? Gastroenteritis (also known as Food Poisoning; Stomach Flu; Travelers Diarrhea ) is the inflammation of the lining of the stomach and small and large intestines. It is a serious condition that often requires emergency surgery. Dietary modifications: nothing by mouth, liquids as tolerated. Ileus is the term for the absence of peristaltic activity in the lower gastrointestinal tract. Learn effective and evidence-based nursing interventions and nursing care management strategies to improve patient outcomes. It is important to identify risk factors as it may influence the choice of medical intervention. Electrolyte washout from the stomach during gastric aspiration may increase if there is an excessive use of ice chips. The nurse can assess by asking the patient to rate their pain with the use of pain assessment tools applicable to the patient and determine whether the pain is constant, aching, stabbing, or burning. Risk for Fluid Volume Deficit. 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. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. However, in the case of bowel perforation, contents of the bowel may leak out through the hole in its wall. Gastrointestinal Care Plans, Nursing Care Plans 7 Gastroesophageal Reflux Disease (GERD) Nursing Care Plans 1. Check the patients frequency of bowel movements. Around 2% of colonoscopies are reported to result in perforations generally, with greater rates during the procedure necessitating therapeutic measures. Buy on Amazon, Silvestri, L. A. B. identifying stressful situations. Examine the color, clarity, and smell of drain outflow. Administer fluids, blood, and electrolytes as prescribed.The goal of fluid resuscitation is to improve tissue perfusion and stabilize hemodynamics. Symptoms of bowel perforation may include the following: When peritonitis occurs secondary to bowel perforation, the abdomen becomes tender and painful on palpation or when the patient moves. The patient will verbalize an understanding of the disease process and its potential complications. A number of risk factors may increase the risk of developing bowel perforation including: The abdominal cavity, which encloses a number of internal organs, is normally sterile. Endotoxins in the bloodstream eventually cause vasodilation, a fluid shift, and a reduced cardiac output state. 3. This reflects the patients state of total hydration. Get an in-depth understanding of Cholecystectomy Nursing Care Plans and Nursing Diagnosis, including the common nursing interventions and outcomes. Keep all abdominal drains, incisions, open wounds, dressings, and invasive sites sterile at all times. Maegan Wagner is a registered nurse with over 10 years of healthcare experience. To help in the excretion of toxins and to improve renal function, diuretics may be taken. Bowel Perforation. The patient will identify the relationship of signs/symptoms to the disease process and associate these symptoms with causative factors. Nursing Diagnosis: Deficient Fluid Volume related to fever/hypermetabolic state and fluid shifting into intestines and/or peritoneal space from extracellular secondary to bowel perforation as evidenced by hypotension, tachycardia, decreased urine output, concentrated urine, poor skin turgor, delayed capillary refill, dry mucous membrane, and weak peripheral pulses. Bowel perforation is typically diagnosed through a combination of physical examination, imaging tests, and laboratory tests. 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. Administer antiemetics or antipyretics as indicated. Assess the clients pain characteristics.The assessment of pain includes the location, characteristics, severity, palliative, and precipitating factors of the pain. The patient will accurately perform necessary procedures and explain reasons for these actions. Measure the patients abdominal circumference and be mindful of any trends. Risk for infection. Desired Outcome: The patient will maintain passage of soft, formed stool at a regular frequency. This exposes the structures within the peritoneal cavity to gastrointestinal contents. C. eating meals when desired. Clients description of response to pain. Assess laboratory values.Alterations in laboratory values like white blood count can indicate infection. Place the patient in the recumbent position with the legselevated to prevent hypotension, or place the patient onthe left side to prevent. Patients with bowel perforation have a very high risk of developing an infection. Instruct patient about particular foods that will upset thegastric mucosa, such as coffee, tea, colas, and alcohol,which have acid-producing potential. Helicobacter pylori is considered to be the major cause of ulcer formation. Assess the patients neurological status, taking into account any changes in consciousness or newly developed confusion. Surgery may be necessary if bleeding is severe and tests cant visualize the source. What are the common causes of bowel perforation? Other causes include medications, food poisoning, infection, and metabolic disorders. Sedentary lifestyle and lack of activity contribute to constipation. Positioning: maintain an upright position at least 2 hours after meals. Attainment or progress toward desired outcomes. Changes in BP, pulse, and respiratory rate. Response to interventions, teaching, and actions performed. 3. Avoid foods that trigger reflux such as fried foods, fatty foods, caffeine, garlic, onions and chocolate. Its important to also assess the exact location of abdominal pain. The surgery is used when peptic ulcer disease causes pain or bleeding that doesn't improve with non-surgical therapies. For the third spacing of fluid, take measurements from the following: stomach suction, drains, dressings, Hemovacs, diaphoresis, and abdominal circumference. Major Nursing Issues and Interventions . Absence of complications. Learn more about the nursing care management of patients with peptic ulcer disease in this study guide. Increased weight increases intraabdominal pressure and may lead to complications. Submit the clients stool for culture.A culture is a test to detect which causative organisms causean infection. Critical lab values such albumin, prealbumin, BUN, creatinine, protein, glucose, and nitrogen balance should be communicated to the provider. Administer antibiotics as indicated.Antibiotics can help prevent and treat infection in patients with bowel perforation. Common causes include bowel obstruction, perforated peptic ulcers, inflammatory bowel disease, and colon cancer. Nursing interventions are also implemented to prevent and mitigate potential risk factors. Stopping the source of gastrointestinal bleeding will also control the fluid volume deficiency. Proton-pump inhibitors may be prescribed to curb stomach acid production. D. Combination of all of the above. 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. We may earn a small commission from your purchase. Peptic ulcer disease may occur in both genders and in all ages. The management of the patient with a peptic ulcer is as follows:. 1. Peristalsis is responsible for motility the movement of food through the gastrointestinal tract, from its entry via the mouth to its exit via the anus. Recommended nursing diagnosis and nursing care plan books and resources. Intractable ulcer. 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. Answer: A. Provide the patient with frequent skin care and maintain a dry and wrinkle-free bedding. This can cause leakage of gastric acid or stool into the peritoneal cavity. These will lessen fluid loss and neutralize stomach acid hopefully preventing further irritation of the GI mucosa. Assess for the presence of bleeding.Take note of any circumstances that may impair the gastrointestinal systems perfusion and circulation (e.g., major trauma with blood loss and hypotension, septic shock). A. Helicobacter pylori Peptic ulcers are more likely to occur in the duodenum. 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. Peptic ulcers occur mainly in the gastroduodenal mucosa. This encourages the use of nutrients and a favorable nitrogen balance in individuals who are unable to digest nutrients normally. Note and report symptoms of penetration (back and epigastric pain not relieved by medications that wereeffective in the past). With age, the incidence rises. As shock becomes refractory, later symptoms include chilly, clammy, pale skin and cyanosis. Monitor for signs and symptoms of infection, such as fever and elevated heart rate. 1. 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. St. Louis, MO: Elsevier. 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. This can cause leakage of gastric acid or stool into the peritoneal cavity. Maintain accurate input and output measurements and correlate it with the patients daily weights. Monitor the patients complete blood count (CBC), hemoglobin and hematocrit (H&H) levels, serum electrolyte, BUN, creatinine, albumin levels. Choices A, B, and D are proper interventions in providing pain control. Other choices are not related to ulcer formation. 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. Teach the patient breathing and visualization techniques and offer diversionary pursuits. This reflects nutrient requirements, condition, and organ function. The nurse can ask and observe for coping mechanisms that the patient uses. This lessens abdominal tension and/or diaphragmatic irritation, which in turn lessens pain by facilitating fluid or wound drainage by gravity. Our website services and content are for informational purposes only. Initial gains or losses reflect hydration changes, while persistent losses imply nutritional deficiency. Reduce interruptions and group tasks to allow for a quiet, restful environment. A peptic ulcer may be referred to as a gastric, duodenal, or esophageal ulcer, depending on its location. Buy on Amazon. Invasive procedure or surgical intervention, Leakage of bowel contents into the peritoneum. Teach patient about prescribed medications, including name. To replace losses and improve gastrointestinal function. 3. Fluid changes, hypovolemia, hypoxia, circulating toxins, and necrotic tissue products can all have an impact on how well the body functions. It is easy for edematous tissue with poor circulation to break down. Prepare patient for possible diagnostic tests. Elsevier, Inc. Gastrointestinal bleeding StatPearls NCBI bookshelf. D. 60 and 80 years. D. administering medications that decrease gastric acidity. Likewise, the continuous release of fluids may cause dehydration. B. Clostridium difficile Patient will be able to appear relaxed and able to sleep or rest appropriately. This helps the patient unwind and could improve their coping skills by refocusing their attention. Collaborate with the interdisciplinary team in creating the plan of care.Collaboration of an interdisciplinary team improves communication and continuity of care. GI bleeding is not an illness in and of itself, but rather a sign of an underlying condition. The perforation of an ulcer can be a life-threatening emergency requiring early detection and, often, immediate surgical intervention. Surgically, esophagomyotomy is done to relieve the lower esophageal stricture. Inadequate participation in care planning, Inaccurate follow-through of instructions, Development of a preventable complication. Nursing Diagnosis & Care Plan Acute Pain r/t Chemical burn of Gastric Mucosa Nursing Interventions - Record reports of pain including severity, location and duration. The most common complication of peptic ulcer disease that occurs in 10% to 20% of patients is: A. Hemorrhage. Continuously monitor ECG fir dysrhythmias resulting from electrolyte disturbances. Knowledge about the management and prevention of ulcer recurrence. The reported rates of complications following percutaneous endoscopic gastrostomy (PEG) tube placement vary from 16 to 70 percent [ 1-5 ]. Peptic ulcer disease may be caused by which of the following? These drugs coat the intestinal wall and absorb bacterial toxins. Nursing Care Plans Related to Gastrointestinal Bleed 3. Assess and monitor the patients urine output. Meanwhile, diarrhea is when there is an increased frequency of bowel movement, altered consistency of stool, and increased amount of stool. 2. Deficient fluid volume associated with gastrointestinal bleeding can be caused by decreased blood volume due to blood loss. Elsevier/Mosby. The client will pass soft, formed stool no more than 3 x a day. St. Louis, MO: Elsevier. Please read our disclaimer. Explain that smoking may interfere with ulcer healing;refer patient to programs to assist with smokingcessation. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions will be directed at the prevention of signs and symptoms. Administer prescribed medications.Give prescribed prophylactic medications, such as antiemetics, anticholinergics, proton pump inhibitors, antihistamines, and antibiotics. Patient will verbalize understanding of the condition and its complications and alert the nurse or provider to signs of infection such as fever or wound drainage. 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. Encourage to increase physical activity and exercise as tolerated. Assess coping mechanisms of the patient.Coping mechanisms assist the patient in enduring, minimizing, and managing stressful circumstances. Since the peritoneum completely covers the stomach, perforation of the wall creates a communication between the gastric lumen and the peritoneal cavity.
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