nursing care plan for gastric perforation

ACCN Essentials of Critical Care Nursing. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance. As an Amazon Associate I earn from qualifying purchases. Care plans covering the disorders of the gastrointestinal and digestive system. Administer fluids, blood, and electrolytes as prescribed.The goal of fluid resuscitation is to improve tissue perfusion and stabilize hemodynamics. Patient will be able to verbalize an understanding of gastrointestinal bleeding, the treatment plan, and when to contact a healthcare provider. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking. Discuss diet and comorbidities.Since bowel obstructions, impaction, and diverticulitis can all lead to bowel perforations, the patient should be instructed on consuming a proper diet, such as increased fiber intake and plenty of fluids if not contraindicated. Dietary modifications: nothing by mouth, liquids as tolerated. Administer fluids and electrolytes as ordered. Statement # 1 Empiric treatment of pyloriis not recommended. St. Louis, MO: Elsevier. Desired Outcome: The patient will pass formed stool no more than thrice per day. Advise patient to eat slowly and chew food well. 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 To stop ongoing diarrhea and minimize pain experience. document.getElementById("ak_js_1").setAttribute("value",(new Date()).getTime()); This site uses Akismet to reduce spam. This is due to a decrease in blood flow and oxygen in the gastrointestinal system. Provide comforting techniques such as massages and deep breathing. Depending on the length of the stay, antibiotics may be continued after release. 2014. Monitor laboratory values (hemoglobin and hematocrit). Encourage to increase oral fluid intake if not contraindicated. This means that while pain may come on suddenly or gradually, its severity typically increases. 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. If left untreated, this may further develop to sepsis or worse, death. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. In juvenile trauma patients, intestinal perforation occurs somewhere between 1% and 7% of the time. Monitor the patients complete blood count (CBC), hemoglobin and hematocrit (H&H) levels, serum electrolyte, BUN, creatinine, albumin levels. Observe and assess the patients level of pain on a scale of 0-10. St. Louis, MO: Elsevier. Thirty minutes later, the JP [Jackson It is important to identify risk factors as it may influence the choice of medical intervention. 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. gram-negative bacteria. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Changes in BP, pulse, and respiratory rate. Maintain accurate input and output measurements and correlate it with the patients daily weights. Nursing Interventions and Rationales Assess and Monitor vitals Monitor for signs and symptoms of infection / inflammation to include: Fever Tachypnea Tachycardia Monitor for signs and symptoms of hypovolemia to include: Hypotension Tachycardia Perform detailed pain assessment Assessment of relief measures to relieve the pain. 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. Choices A, B, and D are proper interventions in providing pain control. Eliminate unpleasant environmental stimuli. This results in loose, watery stools that can lead to dehydration if not treated promptly. - Review factors that aggravate or alleviate pain. She has worked in Medical-Surgical, Telemetry, ICU and the ER. Its important to also assess the exact location of abdominal pain. Anna Curran. Other causes include medications, food poisoning, infection, and metabolic disorders. Insert an indwelling urinary catheter and monitor intakeand output; insert and maintain an IV line for infusinguid and blood. Stools may be hardened, painful to release, and may even remain in the rectum for prolonged periods of time. opioids, antacids, antidepressants, anesthetics, etc. Desired Outcome: The patient will maintain passage of soft, formed stool at a regular frequency. For more information, check out our privacy policy. It is important to provide proper patient education about the condition, prognosis, treatment options, and complications to ensure adherence with the treatment regimen. This helps the patient unwind and could improve their coping skills by refocusing their attention. St. Louis, MO: Elsevier. The nurse includes that the most common cause of peptic ulcers is: 2. In contrast, no client with a duodenal ulcer has pain during the night often relieved by eating food. document.getElementById("ak_js_1").setAttribute("value",(new Date()).getTime()); This site uses Akismet to reduce spam. Complete blood count, basic metabolic panel, and inflammatory markers should also be reviewed to assess signs of infection and determine liver and kidney function. 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. Frequently change the patients position. 1.The client diagnosed with a gastric ulcer, pain usually occurs 30 to 60 minutes after eating, but not at night. The most frequent cause of perforation in the elderly population is perforated appendicitis. 2. its really Help. She received her RN license in 1997. 1. Bowel ischemia and gastrointestinal (GI) hypoperfusion can be caused by blood loss, hypovolemic or hypotensive shock, or both. Assess neuro status including changes in level of consciousness or new onset confusion. This care plan for gastroenteritis focuses on the initial management in a non-acute care setting. Includes: appendectomy, gastroenteritis, inflammatory bowel disease, live cirrhosis, and more. 2. Monitor oxygen saturation and administering oxygentherapy. Patient will participate in care planning and follow-up appointments. Encourage adequate hydration (drink water) Encourage good oral hygiene. Limit the patients intake of ice chips. Ensure infection control precautions are followed.Interventions that can help reduce infection in patients with bowel perforation include meticulous hand hygiene before and after handling the patient, the surgical site, and IV sites or catheters. Get a better understanding of this condition and how to provide the best care for patients. Her experience spans almost 30 years in nursing, starting as an LVN in 1993. 3426-3452). Get answers to commonly nursing interventions and nursing management for effective treatment. Reviewed: July 11, 2022. Administer medications as ordered: antidiarrheals, pain medications. Evaluate the patients skin color, moisture and temperature. Ask the client about arecent history of drinking contaminated water, eating food inadequately cooked, and ingestion of unpasteurized dairy products:Eating contaminated foods or drinking contaminated water may predispose the client to intestinal infection. This reduces the patients urge to vomit and gastrointestinal stimulation. A hole in your stomach or small intestine can leak food or digestive fluids into your abdomen. The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes. Nursing interventions for the patient may include: If perforation and penetration are concerns: The patient should be taught self-care before discharge. Inadequate participation in care planning, Inaccurate follow-through of instructions, Development of a preventable complication. 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. Surgically, esophagomyotomy is done to relieve the lower esophageal stricture. 2. Observe output from drains to include color, clarity, and smell. Nursing Care Plans and Interventions 1. Spontaneous Gastric Perforation. 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. 2. 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. When intake is restarted, the risk of stomach irritation is reduced by a careful diet progression. To help control reflux and cause less irritation to the esophagus. 4. Advance the diet from clear liquids to soft meals. The most common site for peptic ulcer formation is the: A. Duodenum. 1. Fluids are needed to maintain the soft consistency of fecal mass. The patient will verbalize an understanding of the individual risk factor(s). https://www.ncbi.nlm.nih.gov/books/NBK537224/, https://my.clevelandclinic.org/health/diseases/23478-gastrointestinal-perforation, https://www.healthline.com/health/gastrointestinal-perforation, https://www.ncbi.nlm.nih.gov/books/NBK538191/, Sleep Apnea Nursing Diagnosis & Care Plan, Chemotherapy Nursing Diagnosis & Care Plan, Accidental ingestion of harmful objects or substances like batteries, magnets, sharp objects, or any corrosive chemicals, Injury from a traumatic event like a motor vehicle accident, Chemical irritation of the peritoneal cavity. Assess nutritional status.The nurse must take into account the current consumption, weight fluctuations, oral intake issues, supplement use, tube feedings, and other variables (e.g., nausea and vomiting) that may have an adverse impact on fluid intake. Bowel perforation, a serious medical condition requiring emergency medical care, occurs when a hole develops in the bowel wall. In: StatPearls [Internet]. Discuss with the patient the dosage, frequency, and potential negative effects of the medications. Awareness and ability to recognize and express feelings. Teach the patient breathing and visualization techniques and offer diversionary pursuits. Bowel perforation is typically diagnosed through a combination of physical examination, imaging tests, and laboratory tests. Buy on Amazon, Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). This reflects the patients state of total hydration. Overview of gastrointestinal bleeding Gastrointestinal disorders MSD manual professional edition. What are the common causes of bowel perforation? 1. Reduced anxiety. As an Amazon Associate I earn from qualifying purchases. Major Nursing Issues and Interventions . Since analgesics can conceal symptoms and indications, they may be withheld throughout the first diagnostic process. This can cause leakage of gastric acid or stool into the peritoneal cavity. Examine any constraints or limitations on the patients activity (e.g., avoid heavy lifting, constipation). This prevents needless muscle stress and intra-abdominal pressure buildup. Symptomatically, treatment includes dietary modification, an increase in fluid intake, and the use of laxatives. 4. Patients who present with abdominal pain and distension, especially in the right historical context, must be assessed for this entity because a delayed diagnosis increases the risk of developing infections like peritonitis, which can be fatal. Beyond the neonatal period, perforation is rare and usually secondary to trauma, surgery, caustic ingestion, or peptic ulcer. For the third spacing of fluid, take measurements from the following: stomach suction, drains, dressings, Hemovacs, diaphoresis, and abdominal circumference. She earned her BSN at Western Governors University. Stopping the source of gastrointestinal bleeding will also control the fluid volume deficiency. 4. 3. Gastroenteritis (also known as Food Poisoning; Stomach Flu; Travelers Diarrhea ) is the inflammation of the lining of the stomach and small and large intestines. Intestinal perforation, defined as a loss of continuity of the bowel wall, is a potentially devastating complication that may result from a variety of disease processes. 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! Irregular mealtimes may cause constipation. 11th Edition, Mariann M. Harding, RN, Ph.D., FAADN, CNE. 5. This can provide information with regards to the patients infection status. Patients with achalasia are advised to eat slowly and to drink fluids with meals. ulcer surgery, gastric ulcer surgery, or peptic ulcer surgery) is a procedure for treating a stomach ulcer. It also allows the development of an appropriate and suitable treatment plan that will improve systemic perfusion and organ function of the client. Problems related to motility and digestion are common. Disclosure: Included below are affiliate links from Amazon at no additional cost from you. Administer antibiotics as ordered. Elsevier/Mosby. Evaluate the pattern of defecation.The defecation pattern will promote immediate treatment. Medications such as antacids or histamine receptor blockers may be prescribed. Recommend resuming regular activities gradually as tolerated, allowing for enough rest. Determine the patients threshold for bearable pain and give them painkillers to stay within it. It is easy for edematous tissue with poor circulation to break down. Administer fluids and electrolytes as ordered. Response to interventions, teaching, and actions performed. This encourages the use of nutrients and a favorable nitrogen balance in individuals who are unable to digest nutrients normally. The patient will demonstrate employment of relaxation skills and other methods to encourage comfort. Restrict intake of caffeine, milk, and dairy products. Inform the patient about the necessity of using a pillow or other soft object to splint the surgical site in order to reduce pain when moving. Desired Outcome: The patient will pass stool within 48 hours post-appendectomy. Treatment options depend on the severity of the condition and may include surgery to repair the perforation and remove any damaged tissue. Provide the patient with frequent skin care and maintain a dry and wrinkle-free bedding. As directed, administer total parenteral nutrition (TPN) or tube feeds. This reduces diarrhea losses and bowel hyperactivity. 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). Surgery may be necessary if bleeding is severe and tests cant visualize the source. Buy on Amazon. Encourage family to participate in care, and giveemotional support. Medical management includes calcium channel blockers and nitrates as they assist in decreasing esophageal pressure and improving swallowing. Certain drugs can slow down peristalsis and contribute to constipation, i.e. Perforation of the stomach is a full-thickness injury of the wall of the organ. 5. Thank you Marianne! (2020). The bypass involves . NurseTogether.com does not provide medical advice, diagnosis, or treatment. The treatment is symptomatic, although cases of bacterial and parasitic infections require antibiotic therapy. Discover everything you need to know in our comprehensive guide. Diverticulitis Pathophysiology for nursing students and nursing school, Imbalanced Nutrition: Less Than Body Requirements, Conjunctivitis Nursing Diagnosis and Nursing Care Plan, Pancreatic Cancer Nursing Diagnosis and Nursing Care Plan. Discover the key nursing diagnoses for managing inflammatory bowel disease.

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