NURSING CARE PLAN

PROBLEM BASED LEARNING TOPICS

(ULCERATIVE COLITIS, DM TYPE 1 & PEPTIC ULCER DISEASE)

NCM 112B- RLE

SUBMITTED BY:

AGUINALDO, SOPHIA KAYE M.

BSN III – E, GROUP 2

Cluster 1

SUBMITTED TO:

MYRA FABIAN

CLINICAL INSTRUCTOR
 ULCERATIVE COLITIS

NURSING DIAGNOSIS

Risk for deficient fluid volume due to excessive losses through normal routes (diarrhea)

Subjective data:

- Complaints of frequent passage of blood mixed stool for last 2months and the
frequency was about 8-10 times per day associated with low grade intermittent
fever
- Lower abdominal pain and cramping
- Pain in large joints

Objective data:

- looked mildly pale and afebrile

- Vital Signs:
HR- 102/min
BP- 110/80 mmHg
RR-24/min
- weight of 28 kg
- Abdomen was soft, mild tenderness present in lower abdomen

NURSING INFERENCE

Ulcerative Colitis (UC) causes long-lasting inflammation and ulcers in the digestive tract,
usually affecting the innermost lining of the colon. Cause is not completely known, but it is
believed to be related to an immune system dysfunction and heredity. Patients are at
increased risk for developing IBD if they have close family members with the condition or
have long term use of NSAIDS. Complications may include colon cancer, sclerosing
cholangitis and blood clots. Ulcerative colitis may lead to toxic mega colon, perforated colon
and severe dehydration.
NURSING GOAL

After 8 hours of nursing intervention, the patient will be able to:

1. Maintain adequate fluid volume as evidenced by moist mucous membranes, good

skin turgor, and capillary refill; stable vital signs; balanced I&O with urine of normal
concentration/amount.
2. Demonstrate behaviours to monitor and correct deficit, as indicated, when condition
is chronic.

NURSING INTERVENTIONS and RATIONALE

Nursing Intervention Rationale

1. Note possible conditions or

processes that may lead to deficits To assess causative and precipitating factors.
such as fluid loss, limited intake, Fluid loss may be an effect of diarrhea or
fluid shifts, and environmental vomiting).
factor.
2. Monitor I&O. Note number,
Provides information about overall fluid
character, and amount of stools;
balance, renal function, and bowel disease
estimate insensible fluid
control, as well as guidelines for fluid
losses (diaphoresis). Measure urine
replacement.
specific gravity; observe for oliguria.
Hypotension (including postural),
3. Assess vital signs (BP, pulse,
tachycardia, fever can indicate response of
temperature).
fluid loss.
4. Observe for excessively dry skin and
Indicates excessive fluid loss or
mucous membranes, decreased skin
resultant dehydration.
turgor, slowed capillary refill.

5. Weigh the patient daily. Indicator of overall fluid and nutritional

6. Maintain oral restrictions, bedrest;
avoid exertion.
7. Observe for overt bleeding and test
stool daily for occult blood.
8. Note generalized muscle weakness
or cardiac dysrhythmias.
9. Administer parenteral fluids, blood
status.
Colon is placed at rest for healing and to
decrease intestinal fluid losses.
Inadequate diet and decreased absorption
may lead to vitamin K deficiency and defects
in coagulation, potentiating risk of
hemorrhage.
Excessive intestinal loss may lead
to electrolyte imbalance, e.g., potassium,
which is necessary for proper skeletal and
cardiac muscle function. Minor alterations in
serum levels can result in profound or life-
threatening symptoms.
Maintenance of bowel rest requires
 alternative fluid replacement to correct
losses and anemia. Note: Fluids containing
transfusions as indicated.
sodium may be restricted in presence of
regional enteritis.
10. Monitor laboratory studies such
as electrolytes (especially potassium, Determines replacement needs and
magnesium) and ABGs (acid-base effectiveness of therapy.
balance).

NURSING EVALUATION

After 8 hours of nursing intervention, the patient:

1. Maintained adequate fluid volume as evidenced by moist mucous membranes, good

skin turgor, and capillary refill; stable vital signs; balanced I&O with urine of normal
concentration/amount.
2. Demonstrated behaviours to monitor and correct deficit, as indicated, when
condition is chronic.
3. Met the goal.
 DM TYPE 1

NURSING DIAGNOSIS

Fluid volume deficient related to osmotic diuresis from hyperglycemia as evidence by

severe vomiting and excessive thirst

Subjective data:

Complains of nausea and vomiting for two days and symptoms of confusion

Objective data:

Sudden loss of weight around 6 kilograms over 3 months

Extreme thirst (dehydration)

Dry mucous membrane

Biochemical evaluation:

- fasting plasma glucose –280 mg/dl

- postprandial plasma glucose – 380 mg/dl
- HbA1c – 10.5%
- glutamic acid decarboxylase antibody positive

NURSING INFERENCE

Diabetes mellitus (DM) is a chronic metabolic disorder caused by an absolute or relative

deficiency of insulin, an anabolic hormone. Type 1 diabetes mellitus can occur at any age
and is characterized by the marked and progressive inability of the pancreas to secrete
insulin because of autoimmune destruction of beta cells. It is commonly occurs in children,
with a fairly abrupt onset; however newer antibody test have allowed for the identification
of more people with the new-onset adult form of type 1 diabetes mellitus called latent
autoimmune diabetes of the adult (LADA). The distinguishing characteristic of a patient with
type 1 diabetes is that, if his or her insulin is withdrawn, ketoacidosis develop. Therefore,
these patients are dependent on exogenous insulin

NURSING GOAL

After 8 hours of nursing interventions, the patient will be able to demonstrate adequate
hydration.
NURSING INTERVENTIONS and RATIONALE
Nursing Intervention Rationale

Independent:

1. Monitor orthostatic blood pressure Hypervolemia may be manifested by

changes. hypotension and tachycardia.

2. Monitor respiratory pattern like Lungs remove carbonic acid through

Kussmaul’s respirations and acetone respirations, producing a compensatory
breath. respiratory ketoacidosis.

Fevers, chills and diaphoresis are common

3. Monitor temperature, skin color and
with infectious process; fever with flushed,
texture.
dry mucous may reflect dehydration.

Provides on-going estimate of volume

4. Monitor input and output. Note
replacement needs, kidney function and
urine specific gravity.
effectiveness of therapy.

Provide the best assessment of current fluid

5. Weigh the patient daily.
status and adequacy of fluid replacement.

6. Maintain fluid intake at least 2500

ml/day within cardiac tolerance with Maintains hydration and circulating volume.
oral intake is resumed.

7. Promote comfortable environment. Avoid overheating, which could promote

Cover patient with light sheets. further fluid loss.

Collaborative:

Type and amount of fluid depend on the

1. Administer fluid as indicated. degree of deficit and individual patient
response.

NURSING EVALUATION
After 8 hours of nursing interventions, the patient was able to demonstrate adequate
hydration evidence by proper fluid volume intake, palpable peripheral pulses and good
capillary refill.

PEPTIC ULCER DISEASE

NURSING DIAGNOSIS

Acute pain related to hyperacidity secondary to irritation of gastric mucosa

Subjective Data:

- passage of black -tarry stools for almost 3 days

- almost “unbearable pain” after meal for the past 2 days

Objective Data:

- looked pale and afebrile

- vital signs were taken as follows:
HR- 102bpm
BP- 90/60 mmHg
RR- 21bpm
- Abdominal tenderness
- rebound tenderness present in epigastrium (Burning) with noticeable guarding
behavior on the area
- globularly enlarged

NURSING INFERENCE

Peptic ulcer disease is recurring formation of gastric and/or duodenal peptic ulcers. It is also
a condition in which painful sores or ulcer develops in the lining of the stomach or the first
part of the small intestine. The leading symptom is epigastric pain or epigastric discomfort.

NURSING GOAL

After 1-2 hours of nursing intervention, the patient will be able to:

1. Verbalize relief of pain.

2. Demonstrate relaxed body posture and be able to sleep or rest appropriately.
NURSING INTERVENTIONS AND RATIONALE
Nursing Intervention
Independent:
1. Note reports of pain, including
location, duration, and intensity (0-10
scale).
2. Review factors that aggravate or
alleviate pain.
3. Identify and limit foods that create
discomfort such as spicy or
carbonated drink.
4. Encourage small, frequent meals.
5. Encourage patient to assume position
of comfort.
Collaborative:
1. Provide and implement prescribed
dietary modifications.
2. Administer medication as indicated.
Analgesics. e.g., morphine sulfate
Antacids
Anticholinergics, e.g., belladonna,
atropine
NURSING EVALUATION
After 1-2 hours of nursing intervention, the patient:
1. Verbalized relief of pain.
2. Demonstrated relaxed body posture and be able to sleep or rest appropriately.
Rationale
Pain is not always present, but if present
should be compared with patient’s previous
pain symptoms. This comparison may assist
in diagnosis of etiology of bleeding and
development of complications.
Helpful in establishing diagnosis and
treatment needs.
Food has an acidic neutralizing effect and
dilutes the gastric contents.
Small meals prevent distension and the
release of gastrin.
Reduces abdominal tension and promotes
sense of control.
Patient may receive nothing by mouth (NPO)
initially. When oral intake is allowed, food
choices depend on the diagnosis.
May be narcotic to relieve acute or severe
pain and reduce peristaltic activity.
Note: Meperidine (Demerol) has been
associated with increased incidence of
nausea/vomiting.
Decrease gastric acidity by absorption or by
chemical neutralization. Evaluate choice of
antacid in regard to total health picture, e.g.,
sodium restriction
May be given at bedtime to decrease gastric
motility, suppress acid production, delay
gastric emptying, and alleviate nocturnal
pain associated with gastric ulcer.