Name: Mr.

X Age: 24 years old Diagnosis: Upper Gastrointestinal Bleeding ASSESSMENT Subjective: masakit ang tiyan ko as verbalized by the patient Objective: -facial grimace -pain scale of 6/10 -(+)muscle guarding -unresponsive NURSING DIAGNOSIS Acute pain R/T Upper gastro intestinal bleeding AEB facial grimace muscle guarding behavior and being unresponsive. NURSING ANALYSIS The pathogen Helicobacter pylorus penetrates the mucosal lining of the stomach thus causing inflammation which later causes infection. With this situation, injury to the mucosa is inevitable. This injury will let hydrochloric acid and pepsin to seep into the mucosal lining which causes the pain experienced by the patient.
GOALS AND OUTCOME
NURSING INTERVENTION
INDEPENDENT 1) Obtain clients assessment of pain to include location, characteristics, onset and duration, frequency, quality, intensity, and precipitating factors. 2)Monitor skin color and vital signs 3)Encourage deepbreathing exercise 4) Promote Bed Rest 5)Provide comfort measures, quiet environment and calm activities DEPENDENT 6)Evaluate and document clients response to analgesic and assist in transitioning or altering drug regimen, based on the individual needs and protocol 7) Administer analgesics as ordered COLLABORATIVE 8)Collaborate in the treatment of underlying disease process causing pain 9)Provide for individualized physical therapy or exercise program that can be continued by the patient after discharge

RATIONALE
1) To rule out worsening of underlying condition or development of complications.

EVALUATION Goal Met: After 8 hours of Nursing Intervention , the patient reported a decreased of pain scale from 6/10 to 3/10, demonstrated increased interest in participating in the several activities and lessen facial grimace and muscle guarding behavior.

Goal: the patient will report decrease in pain within 8 hours of Nursing Intervention As Evidenced By pain scale of 6/10 to 3/10, increase interest to several activities, and lessen facial grimace and muscle guarding behavior.

2)These are usually altered in acute pain 3)To distract attention and remove tension 4)To prevent fatigue 5) To promote nonpharmacological pain management

6) Increasing or decreasing dosage, stepped program helps in self management of pain.

7)to maintain acceptable level of pain 8) To alleviate the anxiety and to treat the cause of pain 9)Promotes active, rather than passive, role and enhances sense of control

NURSING CARE PLAN

Name: Mr. X Age: 24 years old Diagnosis: Upper Gastrointestinal Bleeding ASSESSMENT Subjective: Nagsusuka kasi ako as verbalized by the patient Objective: -poor skin turgor -dry mucous membrane -weakness -pulse rate of 51bpm NURSING DIAGNOSIS Fluid Volume Deficient R/T excessive vomiting AEB weakness, dry mucous membrane with poor skin turgor and pulse rate of 51bpm. NURSING ANALYSIS Due to the penetration of organisms in the intestine, metabolic processes happening inside the body is disturbed. As one of the reaction of our body, the occurrence of excessive vomiting is being observed. As a result extreme fluids being expelled in the system leading to dehydration or water loss alone without change in sodium.
GOALS AND OUTCOME
NURSING INTERVENTION

RATIONALE

EVALUATION GOAL MET: The clients fluid volume had maintained at a functional level as evidenced by moist mucous with fair skin turgor, decreased weakness as reported by the patient and stable vital signs with a pulse rate of 75bpm.

Goal: The client will maintain fluid volume at a functional level as evidenced by moist mucous membrane with fair skin turgor, report of decrease weakness and stable vital signs.

INDEPENDENT 1)Note the characteristics of vomitous 2)Monitor vital signs 3) Advise the patient to increase fluid intake 4) Encourage the patient to increase the intake of foods rich in Vitamin C 5)Promote bed rest 6)Change position frequently 7)Provide frequent oral as well as eye care DEPENDENT 8)Administer antiemetic as ordered 9) Administer other medications as ordered COLLABORATIVE 10) Administer IV fluids, as indicated or plasma expander as indicated.

1)May be helpful in determining the cause of gastric distress 2) To serve as a baseline data 3) To replace fluid volume loss 4) To boost the immune system

5)To prevent fatigue 6) To reduce pressure on the fragile skin and tissues 7)To prevent injury from dryness 8)To lessen the occurrence of vomiting and lessen intestinal losses 9) To treat underlying illness or condition.

10) To further replace the fluid loss and prevent dehydration

NURSING CARE PLAN

Name: Mr. X Age: 24 years old Diagnosis: Upper Gastrointestinal Bleeding ASSESSMENT NURSING DIAGNOSIS NURSING ANALYSIS As an outcome of penetration of the foreign organism inside the linings of the gastrointestinal tract, the white blood cells increased in number as the primary defense of our system. As a result body temperature elevates above normal range since there is an entry of organisms which is not recognized by the body that disturbs the normal processes happening inside the mentioned system. This reaction of our body further gives a sign of infection. GOAL AND OUTCOME GOAL: Clients body temperature will decrease from 38.2 to 37.6 within 8 hours of Nursing Intervention.
NURSING INTERVENTION

RATIONALE

EVALUATION GOAL MET: Clients body temperature decreased from 38.2 to 37.5 in less than 8 hours of Nursing Intervention

Subjective: Hyperthermia R/T nilalagnat ako as disease process as verbalized by the client evidenced by skin is warm to touched, Objective: flushed skin, -skin is warm to temperature of 38.2 touched and weakness -flushed skin -febrile at 38.2 degree Celsius -weakness

INDEPENDENT
1)Monitor the Vital signs 2)Render Tepid Sponge Bath 1)It serves as a baseline data and to know any changes 2) Helps to decrease temperature by conduction and evaporation. 3)To expel the heat through urination 4)To boost the immune system 5) Heat loss by radiation and conduction 6) To prevent other occurrence of illness 7) To reduce metabolic demand

3) Advise the patient to increase fluid intake 4) Emphasize the increase intake of citrus fruits 5) Promote cool surface by means of dressing comfortable dress or by undressing 6) Keep back dry 7)Encourage Complete bed rest

DEPENDENT
8)Administer antipyretics as ordered 9)Administer other medications as ordered 8)To help lessen the temperature of the patient 9) To treat underlying cause of the situation 10)To support circulating volume and tissue perfusion 11)To meet increased metabolic demands

COLLABORATIVE
10)Administer replacement of fluids and electrolytes 11)Provide high-calorie diet, enteral or parenteral nutrition

NURSING CARE PLAN

Name: Mr. X Age: 24 years old Diagnosis: Upper Gastrointestinal Bleeding ASSESSMENT Subjective: Minsan nahihilo pa rin ako, as stated by the patient NURSING DIAGNOSIS Risk for fall related to disease process NURSING ANALYSIS Due to the illness obtained by the client that has a sign and symptoms of drowsiness the client might have an increase susceptibility to falling that may cause physical harm. Prior to this there is imbalance nutrition occurring due to the disturbance of the processes inside the body.
GOAL AND OUTCOME
NURSING INTERVENTION

RATIONALE
1)Child, young adult, elderly women are @ greater risk 2)Affects ability to perceive own limitations and risk for falling 3) Individuals temperament, typical behavior, stressors and level of self-esteem can affect attitude toward safety issue resulting in carelessness/increased risk taking without considerations of consequences 4) Client caregivers may not be aware of proper precautions/may not have knowledge, desire/resources to attend to safety issues in all settings 5)use of pain medication may attribute to weakness and confusion, multiple medications and combinations of medications affecting BP or cardiac function may contribute to dizziness or loss of balance.

EVALUATION GOAL MET: The client understood the directions give by the student nurse about the safety precautions needed to perform.

Goal: The client will verbalize understanding of individual risk factors by demonstrating behaviors/lifestyle changes to reduce the susceptibility to injury.

INDEPENDENT 1)Note the age and sex 2)Evaluate client cognitive status 3)Assess mood, coping abilities, personality styles

4)Ascertain knowledge of safety need injury prevention and motivation to prevent injury DEPENDENT 5) Review medication regimen and how it affects client. Instruct in monitoring of effects/side effects

COLLABORATIVE 6)Refer to physical or occupational therapist appropriate

6)may require exercises to improve strength or mobility, improve or relearn ambulation, identify and obtain appropriate assistive device for mobility but room safety or home modification.

NURSING CARE PLAN

Name: Mr. X Age: 24 years old Diagnosis: Upper Gastrointestinal Bleeding ASSESSMENT Subjective: Marumi ang ibang gamit dito at maalikabok ang kapaligiran paminsanminsan, as stated by the patient NURSING DIAGNOSIS Risk for infection related to poor hygiene and environmental sanitation NURSING ANALYSIS If the sanitation of the environment could in the place where the clients stays could not be improve more it predispose the client to complications related to her condition. Proper hygiene also affects the clients condition because it needs improvement on the cleanliness. GOAL AND OUTCOME GOAL: Clients body will be able to fight against infections and complications through behaviors/lifestyle changes
NURSING INTERVENTIONS
INDEPENDENT 1)Instruct client in aseptic/clean techniques such as proper handwashing 2)Discuss the importance of reporting of changes in condition or any unusual physical discomforts/changes 3)Emphasize the need for adequate nutritional intake high in protein and vitamin C and sufficient fluid intake 4)Encouraged client to stick on maintaining a proper hygiene 5)Discuss with the helpers in the institution the importance of having a clean environment not just for the clients but for all of them DEPENDENT 6)Discuss importance of not taking antibiotics/using leftover drugs unless specifically instructed by the healthcare providers 7)Emphasize necessity of taking antibiotics as directed

RATIONALE
1)To prevent spread of infectious agents and reduces risk of infection 2)Promotes early detection of developing complications

EVALUATION GOAL MET: The client was able to made changes and followed interventions to prevent infections and complications

3)Adequate proteins helps the immune system to produce more antibodies to fight against infection 4)A proper personal hygiene will help the clients condition not to worsen 5)A clean environment will promote a place that is free of complications

6)Inappropriate use can lead to development of drugresistant strains/ secondary infection 7)Premature discontinuation of treatment when client begins to feel well may result in return of infection

COLLABORATIVE 8)Identify resources available to the individual

8) To be more oriented to the facilities of the agency and to make surrounding better.

NURSING CARE PLAN