Student Nurses’ Community

NURSING CARE PLAN – Upper Gastrointestinal Bleeding

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Acute or Acid, pepsin, and After 4 hours of Independent  Pain is not always After 4 hours of
chronic pain helicobacter nursing  Note reports of present, should nursing
“Napakasakit ng maybe related infection play an interventions, the interventions, the
pain, including be compared with
Patient was able to
tiyan ko” (I’m to chemical important role in Patient verbalize location, duration, patient’s previous verbalize relief of
having severe burn of gastric the development relief of pain and and intensity (0-10 pain symptoms. pain and
stomach pain) as mucosa, oral of gastric ulcers. demonstrate scale). The comparison demonstrate relaxed
verbalized by the cavity and The gastric relaxed body may assist in body posture and be
patient. physical mucosal barrier posture and be  Review factors that diagnosis of able to sleep or rest
response such overlies the able to sleep or aggravate or etiology of properly.
as flex muscle epithelium. The rest properly. alleviate pain. bleeding and
spasm in the secretion of development of
OBJECTIVE: stomach wall. mucus and  Note nonverbal complications.
bicarbonate pain cues.
 Abdominal provides a first  Helpful in
guarding line defense in  Provide small establishing
 Rigid body maintaining a frequent meals. diagnosis and
posture near-normal pH treatment needs.
 Facial on the gastric  Identify and limit
grimacing epithelium and foods that create
protects the discomfort.  Non-verbal cues
mucosal barrier may be both
 V/S taken as against acid.  Assist with active physiological and
follows Gastromucosal and passive range psychological and
prostaglandins of motion may be use in
T: 37.3˚C increase the exercises. conjunction with
P: 89 barrier’s verbal cues to
R: 19 resistance to evaluate extent
 Provide frequent
BP: 110/ 80 ulceration. The and severity of
oral care and
integrity of the the problem.
comfort measures
barrier is
including back rub
enhanced by the  Food has an acid-
and position
rich blood supply neutralizing effect
change.
of the mucosa of and dilutes the
the stomach and gastric contents.
duodenum. Small meals
Student Nurses’ Community

prevent distention
and the release of
Collaborative gastrin.

 Provide and
implement dietary  Specific foods that
modifications. cause distress
vary among
 Use regular than individuals. Spicy
skim milk, if milk is foods, alcohol,
allowed. and coffee can
precipitate
 Administer dyspepsia.
medications as
indicated such as  Reduces joint
analgesics. stiffness,
minimizing pain
and discomfort.

 Halitosis from
stagnant oral
secretions is
unappetizing and
can aggravate
nausea.

 Client may receive

nothing by mouth
initially. When
oral intake is
allowed, food
choices depend
on the diagnosis
and etiology of
the bleeding.
Student Nurses’ Community

 Fat in regular milk

may decreases
gastric
secretions. The
calcium and
protein content
especially in skim
milk increases
secretions.

 Helps relive acute

or severe pain.