Nursing Care Plan to the Client with a Peptic Ulcer

من طرف محمد حبيب الإثنين ديسمبر 21, 2009 8:32 pm

Nursing Care Plan to the Client with a Peptic Ulcer
Nursing Assessment

1. Assess for chronic use of certain medications (such as aspirin, steroids).
2. Collect information of complaints that brought client to the hospital.
3. Obtain history of onset and progression of symptoms.
4. Obtain information of diet, use of alcohol and tobacco, ingestion of irritating foods, previous diseases or infections of GI tract, emotional stress.
5. Assess connection of pain attacks to meals, certain drugs, ingestion of coffee, alcohol.
6. Perform complete physical assessment including weight, vital signs, signs of GI bleeding, and acute abdomen.
7. Assess diagnostic tests and procedures for abnormal values.

Nursing Diagnosis

1. Increased risk of GI bleeding and perforation of stomach, related to gastric or intestinal wall erosion.
2. Increased risk of pyloric obstruction as complication of the peptic ulcer.
3. Increased risk of anemia due to acute or chronic GI bleeding, related to ulcer.
4. Pain and heartburn, related to diagnosis of peptic ulcer.
5. Appetite changes and weight changes due to symptoms of the ulcer.
6. Increased risk of aspiration due to vomiting, related to ulcer.
7. Anxiety related to the symptoms of disease and fear of the unknown.

Nursing Plan and Interventions

Goals

1. Reduce or completely eliminate contributing factors.
2. Assist with stress management.
3. Promote adequate nutrition.
4. Prevent avoidable injury.
5. Then surgical intervention prescribed, prevent postoperative complications.
6. Relief or diminish symptoms.
7. Decreased anxiety with increased knowledge of disease, it treatment, way of prevention and follow-up.

Interventions

1. Assess, report , and record signs and symptoms and reactions to treatment.
2. Monitor fluids input and output closely.
3. Administer antacid agents, analgesics, H2-receptors antagonists, anticholinergics, sedatives as prescribed, monitor for side effects.
4. Monitor client’s vital signs and signs of possible GI bleeding or perforation closely.
5. Monitor laboratory tests results (CBC, electrolytes, Hb levels) for abnormal values.
6. Undertake appropriate intervention in case of GI bleeding, vomiting, or perforation.
7. Provide prescribed diet – avoid irritating foods, coffee, etc.
8. Prepare client and his family for surgical intervention if required for recurrent ulcer, hemorrhage, or perforation.
9. For client after surgical intervention provide postoperative care and inform about possible postoperative complications, such as dumping syndrome.
10. Provide emotional support to client, explain all procedures to decrease anxiety and to obtain cooperation.
11. Instruct client regarding disease progress, diagnostic procedures, treatment and its complications, home care, daily activities, diet, restrictions and follow-up.

Evaluation

1. Reports increased comfort, decreased anxiety.
2. Verbalizes absence of heartburn and pain.
3. No evidence of nausea, vomiting, GI bleeding, or acute abdomen.
4. Maintains stable vital signs, fluid balance, and body weight.
5. Laboratory tests results shows no abnormalities.
6. No postoperative complications.
7. Demonstration of understanding of disease progress, diagnostic and treatment procedures, prevention, and need for follow-up.

مع تحياتي إلى الجميع محمد حبيب