Nursing Diagnosis: Increased risk of GI bleeding and perforation of stomach, related to gastric or intestinal wall

erosion.
ASSESSMENT EXPECTED OUTCOME NURSING INTERVENTION RATIONALE EVALUATION
Subjective: At the end of our nursing | INDEPENDENT: At the end of our nursing
“mao na hospital intervention the patient will -assessed patient’s intervention objectives are
k okay gasuka manifest decreased GI -to determine any
vital signs. partially met as evidenced
man gud kog bleeding as evidence by: deviation from
by:
dugo didto normal and for
Decreased episode of
shop.”as baseline data. “wala naman ko
hematemesis
verbalized by the nagsukag
Maintains stable vital -encourage patient to -to prevent irritation
patient. dugo,akong tae wala
signs (within normal decrease intake of of the eroded
Objective: naman kaayoy
level.) acidic foods. intestinal wall.
- Skin pale dugo”as verbalized
Maintain fluid and
-hematemesis -provide health
electrolyte balance -to increase patient’s by the patient.
-dark tarry teaching to the
Laboratory tests knowledge about the Blood pressure within
stools. patient about the
results shows no effects of alcohol in normal
- abdomen effects of alcohol
abnormalities. the GI tract. level=130/70mmhg
distended and intake.
Report increase comfort. Increased fluid intake
tender with -instruct patient to -nicotine can
Decrease episode of
hyperactive Report comfort
eliminating dark tarry avoid cigarette increase GI
bowel sounds. Decreased episode
stools. smoking. secretions.
-hematocrit=27 of eliminating black
-platelet
-encouraged patient
-to maintain fluid in tarry stools.
count=124 to drink 6 glasses of
the body.
-blood water in a day.
pressure:100/70 -encourage patient to -to decreased
mmhg eat more fiber-rich episode of
foods eliminating hard
| DEPENDENT stools.
/COLLABORATIVE:
- Monitor fluids input and
output closely.
-administer anti-ulcer drug:
sucralfate 1g +20 ml H20 1
hour before meals then at
bedtime.
-Ferrous sulfate 1 tab TID
-administer Ranitidine
Hydrochloride 50mg IVTT q
8
-to measure the
fluids taken by the
patient.
-to promote ulcer
healing by adhering
duodenal ulcer sites.
-to elevate serum
iron concentration
that helps to form
hGb or trapped in the
reticuloendothelial
cells for storage and
eventual conversion
to a usable form of
iron.
-inhibits the action of
H2 receptors of the
parietal cells thus
inhibiting gastric acid
secretions.