nursing care plan for gastric perforation

The nurse can also provide non-pharmacologic pain management interventions such as relaxation techniques, guided imagery, and appropriate diversional activities to promote distraction and decrease pain. Treatment options depend on the severity of the condition and may include surgery to repair the perforation and remove any damaged tissue. 2. C. 40 and 60 years. 2. Imbalanced Nutrition: Less Than Body Requirements, All-in-One Nursing Care Planning Resource E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health, Nursing Care Plans (NCP): Ultimate Guide and Database, Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing, 10 Differences: Textbook Nursing vs Real Life Nursing, Bacterial, viral, or parasitic infections. Assessment of the characteristics of the vomitus. Nurses Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. 1. The complete lack of or ineffective peristalsis in the esophagus with the inability of the esophageal sphincter to relax in response to swallowing is termed achalasia. Sedentary lifestyle and lack of activity contribute to constipation. 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. The leaked bowel contents may also cause abscess formation leading to an excruciating infection called peritonitis. The type of pain presented may assist in narrowing down the type of IBD the patient has. To reduce pressure on abdominal surgery wounds, keep the patient in a semi-Fowler position. Monitor oxygen saturation and administering oxygentherapy. When the patient develops cyanotic, cold, and clammy skin, this can indicate septic shock from peritoneal infection. Keep all abdominal drains, incisions, open wounds, dressings, and invasive sites sterile at all times. Anna Curran. These complications include hemorrhage(cool skin. Assessment of relief measures to relieve the pain. 3. Recommend patient to maintain a normal weight, or to lose weight if needed. Assess neuro status including changes in level of consciousness or new onset confusion. She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. Assess laboratory values.Alterations in laboratory values like white blood count can indicate infection. Encourage patient to eat regularly spaced meals in arelaxed atmosphere; obtain regular weights and encouragedietary modications. What are the common causes of bowel perforation? A hole in your stomach or small intestine can leak food or digestive fluids into your abdomen. Peristalsis may be increased, decreased, or may even be absent. Ileus is the term for the absence of peristaltic activity in the lower gastrointestinal tract. The most frequent secondary causes of bowel perforation are inflammation, infection, blockage, trauma, and invasive procedures. Main Article: 5 Peptic Ulcer Disease Nursing Care Plans The goals for the patient may include: Relief of pain. Educate the client about perianal care after each bowel movement.The anal area should be gently cleaned properly after a bowel movement to prevent skin irritation and transmission of microorganisms. What are the signs and symptoms of bowel perforation? its really Help. Nurses pocket guide: Diagnoses, interventions, and rationales (15th ed.). Alert patient to signs and symptoms of complications tobe reported. This is due to a decrease in blood flow and oxygen in the gastrointestinal system. Nursing interventions are also implemented to prevent and mitigate potential risk factors. If the condition does not improve, a surgical intervention called fundoplication may be done. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking. As an Amazon Associate I earn from qualifying purchases. To provide baseline data and determine is fluid and nutrient supplementation is required. Administer pharmacologic pain management as ordered.Because it doesnt induce side effects like stomach pain and bleeding, acetaminophen is typically seen as being safer than other nonopioid pain medicines. Nursing Diagnosis: Dysfunctional Gastrointestinal Motility related to recent surgical procedure as evidenced by difficulty passing stool, hypoactive bowel sounds. 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. Recommended nursing diagnosis and nursing care plan books and resources. D. Stomach. 2. Common causes include bowel obstruction, perforated peptic ulcers, inflammatory bowel disease, and colon cancer. B. Numerous antibiotics also have nephrotoxic side effects that may worsen kidney damage and urine production. Changes in BP, pulse, and respiratory rate. Patient will demonstrate interventions that can improve symptoms and promote comfort. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. The nurse can monitor the vital signs of the patient, especially alterations in the blood pressure and pulse rate which may indicate the presence of bleeding. If left untreated, it can result in internal bleeding, peritonitis, permanent damage to the intestines, sepsis, and death. 1.The client diagnosed with a gastric ulcer, pain usually occurs 30 to 60 minutes after eating, but not at night. [Updated 2022 Aug 14]. In addition to the typical symptoms of a bowel perforation, symptoms of peritonitis might include: The underlying causes of bowel perforation can be categorized based on their anatomic location, however many etiologies are overlapping, and these may include: Bowel perforation can also be caused by medical procedures involving the abdomen which may include: Bowel perforation in children is most likely to occur after abdominal trauma. Assess coping mechanisms of the patient.Coping mechanisms assist the patient in enduring, minimizing, and managing stressful circumstances. B. Clostridium difficile These drugs coat the intestinal wall and absorb bacterial toxins. Encourage adequate hydration (drink water) Encourage good oral hygiene. This reduces diarrhea losses and bowel hyperactivity. To establish the diagnosis of peptic ulcer, the following assessment and laboratory studies should be performed: Once the diagnosis is established, the patient is informed that the condition can be controlled. This prevents needless muscle stress and intra-abdominal pressure buildup. 4. In Brunner and Suddarths textbook of medical-surgical nursing (14th ed., pp. Clients description of response to pain. Problems related to motility and digestion are common. Frequently change the patients position. In contrast, no client with a duodenal ulcer has pain during the night often relieved by eating food. Patient will verbalize understanding of the condition, its complications, and the treatment regimen. 6. This prevents weariness and improves wellbeing. 4. This shows abnormalities in renal function and the status of hydration, which may signal the onset of acute renal failure in response to hypovolemia and the effects of toxins. 2. Depending on the length of the stay, antibiotics may be continued after release. 1. Learn more about the nursing care management of patients with peptic ulcer disease in this study guide. Duodenal ulcers cause bowel perforation at a rate that is 2- to 3-times higher than stomach ulcers do, making ulcerative disease the most common cause of bowel perforation in adults. Identify the signs and symptoms that necessitates prompt medical evaluation: persistent abdominal pain and discomfort, nausea, vomiting, fever, chills, or purulent drainage, edema, or erythema around a surgical incision (if present). Nursing Care Plans Related to Gastrointestinal Bleed This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. 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. Administer medications as ordered.Antacids. Desired Outcome: The patient will pass stool within 48 hours post-appendectomy. Provide comfort measures and non-pharmacologic pain management.The nurse can provide comfort measures such as frequent positioning, back rubs, and pillow support. Hypovolemia and reduced renal perfusion may reduce urine production, yet weight gain due to ascites accumulation or tissue edema may still occur. Patient will be able to verbalize an understanding of gastrointestinal bleeding, the treatment plan, and when to contact a healthcare provider. Helicobacter pylori is considered to be the major cause of ulcer formation. Medical-surgical nursing: Concepts for interprofessional collaborative care. Gastrointestinal bleeding StatPearls NCBI bookshelf. MSD Manual Professional Edition. 4. B. Esophagus. F A Davis Company. From: Gastrointestinal Perforation. Prepare the patient for surgery.Bowel perforation may be treated through a laparoscopic procedure, or endoscopy, or if severe, may result in a colostomy. Without prompt treatment, gastrointestinal or bowel perforation can cause: Internal bleeding and significant blood loss. All the best with your nursing career and the little one! Discover the nursing diagnoses for liver cirrhosis nursing care plans. Buy on Amazon. Administer fluids and electrolytes as ordered. Peritonitis, inflammation of the inner abdominal wall lining. Immediate medical care must be provided to patients with bowel perforation to prevent complications. 1. These notes are a-mazing! Feeling of emptiness that precedes meals from 1 to 3 hours. Examine any constraints or limitations on the patients activity (e.g., avoid heavy lifting, constipation). Thanks for the questions I have learned something. Patient Assessment Assess tissue perfusion. Nursing care plans: Diagnoses, interventions, & outcomes. Abdominal surgery recently or in the past, Trauma to the pelvis or abdomen, such as from an accident, Scar tissue formation, typically from a prior operation, in the pelvic area, Being assigned female at birth because a surgery can more readily injure the colon, Hemodynamic instability leading to hypoperfusion, Infection such as peritonitis, local abscess formation, or systemic bacteremia, Fistula formation, bowel obstruction, and hernia formation secondary to postoperative adhesions, The patient will achieve timely healing and be free of fever and purulent drainage or erythema. Peptic ulcers occur with the most frequency in those between the ages of: A. Place the patient in the recumbent position with the legselevated to prevent hypotension, or place the patient onthe left side to prevent. document.getElementById("ak_js_1").setAttribute("value",(new Date()).getTime()); This site uses Akismet to reduce spam. Give regular oral care. This care plan for Gastroenteritis focuses on the initial management in a non-acute care setting. These contents can range from feces from a more distal location of perforation to extremely acidic gastric contents in more proximal bowel perforation. Maintain NPO by intestinal or nasogastric aspiration. 1. If the client is unable to communicate, the nurse should assess the patients physiological and nonverbal pain cues. Educate the patient to avoid triggers. In addition, the nursing care plan should focus on educating the patient on proper hygiene and food handling practices to prevent future episodes of gastroenteritis. 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 - Identify and limit foods that aggravate condition or cause increased discomfort. The nurse can interview the client and review the health history to determine the risk factors and bleeding history of the client. Teach the patient breathing and visualization techniques and offer diversionary pursuits. Administer medications as ordered: antidiarrheals. Nursing care for bowel perforation includes treating the underlying condition, hemodynamic stabilization, preparing the patient before and after surgical and medical intervention, promoting comfort, patient education, and preventing complications such as abscesses or fistulas. The nurse includes that the most common cause of peptic ulcers is: Eat meals at least 2 hours before bedtime or lying down to allow the stomach to fully empty. The nurse anticipates that the assessment will reveal which finding? This occurs when there is regurgitation or back-flow of gastric or duodenal contents into the esophagus. Stopping the source of gastrointestinal bleeding will also control the fluid volume deficiency. Upper and lower origins of bleeding are the two main divisions of GI bleeding. From: Intestinal Perforation. She found a passion in the ER and has stayed in this department for 30 years. Interact in a relaxing manner, help in identifying stressors,and explain effective coping techniques and relaxationmethods. Complete blood count, basic metabolic panel, and inflammatory markers should also be reviewed to assess signs of infection and determine liver and kidney function. Awareness and ability to recognize and express feelings. Note occurrence of nausea and vomiting, and its relationship to food intake. Irregular mealtimes may cause constipation. Evaluate for any signs of systemic infection or sepsis.Alterations in the patients vital signs, including a decrease in blood pressure, increased heart rate, tachypnea, fever, and reduced pulse pressure, can indicate septic shock, leading to vasodilation, fluid shifting, and reduced cardiac output. Encourage to increase oral fluid intake if not contraindicated. Statement # 1 Empiric treatment of pyloriis not recommended. 3rd Edition. Bowel perforation is typically diagnosed through a combination of physical examination, imaging tests, and laboratory tests. Lavage can be utilized to treat poorly localized or distributed inflammation as well as remove necrotic waste. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. This includes measurements of all intake (oral and IV) as well as losses through vomiting, urine, and bloody stools. Stomach ulcer surgery (a.k.a. It is either caused by bacteria or chemicals, can either be primary or secondary, and acute or chronic. The patient should be kept NPO and may require nasogastric decompression. Encourage increase fluid intake of 1.5 to 2.5 liters/24 hours plus 200 ml for each loose stool in adults unless contraindicated.Increased fluid intake replaces fluid lost in liquid stools. C. eating meals when desired. The sixteenth edition includes the most recent nursing diagnoses and interventions from NANDA-I 2021-2023 and an alphabetized listing of nursing diagnoses covering more than 400 disorders. 2. However, common signs and symptoms include severe abdominal pain, bloating, nausea and vomiting, fever, chills, and a rapid heartbeat. Patient will be able to demonstrate efficient fluid volume as evidenced by stable hemoglobin and hematocrit. Bloating, vomiting, abdominal cramping, watery stool, and constipation occur as food and fluid are prevented from passing through the intestines. Include also measured losses. To minimize the occurrence of signs and symptoms of GERD and avoid exacerbation of the condition. Other Possible Nursing Care Plans. Increased weight increases intraabdominal pressure and may lead to complications. 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. Food is commonly regurgitated as it does not pass to the stomach, leading to chest pain, heartburn, nausea, and vomiting. Unresolved diarrhea may result in fluid and electrolyte imbalances that may cause cardiac complications. In general, putting the patient in a supine position alleviates the pain. As a result, organs enclosed within the peritoneal cavity are exposed to digestive fluids, forming a hole through the wall of the organ. Reduced anxiety. 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! Nursing Diagnosis: Dysfunctional Gastrointestinal Motility related to limited fluid intake and sedentary lifestyle as evidenced by infrequent passage of stool, straining upon defecation, passage of dry, hard stool. Treatment of this condition depends on its cause. Proton-pump inhibitors may be prescribed to curb stomach acid production. Recommend resuming regular activities gradually as tolerated, allowing for enough rest. The patient will verbalize an understanding of the individual risk factor(s). Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). Nursing interventions are also implemented to prevent and mitigate potential risk factors. Buy on Amazon, Silvestri, L. A. Interprofessional patient problems focus familiarizes you with how to speak to patients. Encourage the client to restrict the intake of caffeine, milk, and dairy products.These food items can irritate the lining of the stomach, hence may worsen diarrhea. Certain drugs can slow down peristalsis and contribute to constipation, i.e. Absence of complications. Pain is typically very bad, and narcotic painkillers may be necessary. Early detection and treatment of developing complications can help prevent progression to severe illness and injury. Measure the patients urine specific gravity. Critical lab values such albumin, prealbumin, BUN, creatinine, protein, glucose, and nitrogen balance should be communicated to the provider. Saunders comprehensive review for the NCLEX-RN examination. Avoid foods that trigger reflux such as fried foods, fatty foods, caffeine, garlic, onions and chocolate. 1. Updated October 6, 2018. 11th Edition, Mariann M. Harding, RN, Ph.D., FAADN, CNE. Men are more likely than women to have vascular disorders and diverticulosis, which makes LGIB more prevalent in men. 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. Spontaneous perforation of the stomach is an uncommon event mainly seen in the neonatal period, the first few days of life, as a cause of pneumoperitoneum. Care plans covering the disorders of the gastrointestinal and digestive system. Kathleen Salvador is a registered nurse and a nurse educator holding a Masters degree. This encourages the use of nutrients and a favorable nitrogen balance in individuals who are unable to digest nutrients normally. Here are five (5) nursing care plans (NCP) for peptic ulcer disease: Hospitalization may be needed for clients who experience severe dehydration as a result of the vomiting and diarrhea. Assessment of the patients usual food intake and food habits. D. 60 and 80 years. St. Louis, MO: Elsevier. To help in the excretion of toxins and to improve renal function, diuretics may be taken. Nursing care plans: Diagnoses, interventions, & outcomes. This lessens abdominal tension and/or diaphragmatic irritation, which in turn lessens pain by facilitating fluid or wound drainage by gravity. Ackley and Ladwigs Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning CareWe love this book because of its evidence-based approach to nursing interventions. Discover everything you need to know in our comprehensive guide. Disclosure: Included below are affiliate links from Amazon at no additional cost from you. As an Amazon Associate I earn from qualifying purchases. Discover the key nursing diagnoses for managing inflammatory bowel disease. Stabilizing the patient is a part of the management while seeking surgical advice. For more information, check out our privacy policy. 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. To determine causative organisms and provide appropriate medications. Stools may be hardened, painful to release, and may even remain in the rectum for prolonged periods of time. Evaluate the patients support system.Patients who undergo serious abdominal surgery will likely require support in the hospital and at discharge. Her experience spans almost 30 years in nursing, starting as an LVN in 1993. 3. 3. Please read our disclaimer. Nursing Care Plan 2.21.2007 NCP Upper Gastrointestinal / Esophageal Bleeding Bleeding duodenal ulcer is the most frequent cause of massive upper gastrointestinal (GI) hemorrhage, but bleeding may also occur because of gastric ulcers, gastritis, and esophageal varices. Reducing the metabolic rate and intestinal irritation caused by circulating or local toxins promotes healing and helps to relieve pain. This can provide information with regards to the patients infection status. This indicates the capacity to resume oral intake and the resumption of regular bowel function. Review with the patient the underlying disease process and anticipated recovery. McGraw Hill Education. The introduction of antibiotics to eradicate H. pylori and of H2 receptor antagonists as a treatment for ulcers has greatly reduced the need for surgical interventions. Meanwhile, diarrhea is when there is an increased frequency of bowel movement, altered consistency of stool, and increased amount of stool. Decreased bowel sounds may indicate ileus. INCIDENCE OF COMPLICATIONS. Bowel perforation results from insult or injury to the mucosa of the bowel wall resulting from a violation of the closed system. - Review factors that aggravate or alleviate pain. Dress surgical wounds aseptically.Surgical wounds can increase the risk of infection due to compromised skin or tissues. Thirty minutes later, the JP [Jackson Risk for infection. Assess what patient wants to know about the disease, andevaluate level of anxiety; encourage patient to expressfears openly and without criticism. Peptic ulcers are more likely to occur in the duodenum. It is a serious condition that often requires emergency surgery. Antipyretics lessen the discomfort brought on by a fever. Use the appropriate solution to clean these sites. 2. 1 - 4, 6 Adhesions resulting from prior abdominal surgery are the predominant cause of . DiGregorio, A. M., & Alvey, H. (2020, August 24). How is bowel perforation diagnosed and treated? 2. 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. Identify current medications being taken by the patient. 4. To make up for blood and fluid loss and to keep GI circulation and cellular function intact, IV fluids, blood products, and electrolytes are often required. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance. 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. Symptoms of ulcer may last for a few days, weeks, months, and may disappear only to reappear, often without an identifiable cause. 3. Knowledge about the management and prevention of ulcer recurrence. 4. Answer: A. Medications such as antacids or histamine receptor blockers may be prescribed. The reported rates of complications following percutaneous endoscopic gastrostomy (PEG) tube placement vary from 16 to 70 percent [ 1-5 ]. Viral gastroenteritis also called stomach flu is a very contagious form of this disease. Ineffective tissue perfusion associated with gastrointestinal bleeding can be caused by any bleeding from the mouth to the anus depending on the location. Burning sensation localized in the back or midepigastrium. Insert an indwelling urinary catheter and monitor intakeand output; insert and maintain an IV line for infusinguid and blood. Our website services and content are for informational purposes only. Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client CareIdentify interventions to plan, individualize, and document care for more than 800 diseases and disorders. It is important to identify risk factors as it may influence the choice of medical intervention. Description of feelings (expressed and displayed). 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. D. Combination of all of the above. Other recommended site resources for this nursing care plan: More nursing care plans related to gastrointestinal disorders: document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Paul Martin R.N. Vomiting, diarrhea, and large volumes of gastric aspirate are signs of intestinal obstruction that need additional investigation. The nurse auscultated over the stomach to confirm correct placement before administering medication. The patient will identify the relationship of signs/symptoms to the disease process and associate these symptoms with causative factors. Healthline. Burning sensation localized in the back or midepigastrium. Common causes of perforation include trauma, instrumentation, inflammation, infection, malignancy, ischemia, and obstruction. D. Pyloric obstruction. This guide covers everything from pre-operative preparation to post-operative management. 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. Administer fluids and electrolytes as ordered. Low levels of Hgb and Hct signal blood loss. The esophagus, stomach, small and large intestine (colon), rectum, and anus are all parts of the GI tract. Nursing Care Plans and Interventions 1. A 74-year-old male had a Foley catheter being used as a gastrostomy tube. 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. Any bleeding that takes place in the gastrointestinal tract is referred to as gastrointestinal (GI) bleeding. Assess the patients neurological status, taking into account any changes in consciousness or newly developed confusion. Patient will be able to verbalize relief or control of pain. Dysfunctional gastrointestinal motility can be defined as the impairment of the digestive tract that results in ineffective gastric activity. Assess the patients level of pain and pain characteristics.Patients typically describe a worsening of abdominal pain and distention with bowel perforation. Here are four (4) nursing care plans (NCP) and nursing diagnoses for Gastroenteritis: Diarrhea. perforation of abdominal structures, laceration of vasculature, open wounds, peritoneal cavity contamination . A peptic ulcer may be referred to as a gastric, duodenal, or esophageal ulcer, depending on its location. Certain food products exacerbate signs and symptoms of GERD. Assess the clients history of bleeding or coagulation disorders.Determine the clients history of cancer, coagulation abnormalities, or previous GI bleeding to determine the clients risk of bleeding issues. This helps determine the degree of fluid deficiency, the efficacy of fluid replacement therapy, and the responsiveness to drugs. Continuously monitor ECG fir dysrhythmias resulting from electrolyte disturbances. 1. Its important to also assess the exact location of abdominal pain. Electrolyte washout from the stomach during gastric aspiration may increase if there is an excessive use of ice chips. It is vital to determine the source and cause of bleeding and intervene. Surgery for intestinal perforation is contraindicated in the presence of general contraindications to anesthesia and major surgery, such as severe heart failure, respiratory failure, or. 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. She has more than 10 years of clinical and teaching experience and worked as a licensed Nursing Specialist in JCI-accredited hospitals in the Middle East.

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