Student Nurses’ Community
NURSING CARE PLAN – Upper Gastrointestinal Bleeding
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE: Acute or chronic Acid, pepsin, and After 4 hours of Independent After 4 hours of
pain maybe helicobacter nursing Note reports of pain, Pain is not always nursing
“Napakasakit ng related to infection play an interventions, the including location, present, should be interventions, the
tiyan ko” (I’m chemical burn of important role in Patient verbalize duration, and compared with Patient was able to
having severe gastric mucosa, the development of relief of pain and intensity (0-10 scale). patient’s previous verbalize relief of
stomach pain) as oral cavity and gastric ulcers. The demonstrate pain symptoms. pain and
verbalized by the physical gastric mucosal relaxed body The comparison demonstrate
patient. response such as barrier overlies the posture and be may assist in relaxed body
flex muscle epithelium. The able to sleep or rest diagnosis of posture and be
spasm in the secretion of mucus properly. etiology of bleeding able to sleep or rest
stomach wall. and bicarbonate and development of properly.
OBJECTIVE: provides a first line complications.
defense in Review factors that Helpful in
Abdominal maintaining a near- aggravate or alleviate establishing
guarding normal pH on the pain. diagnosis and
Rigid body gastric epithelium treatment needs.
posture and protects the Note nonverbal pain Non-verbal cues
Facial mucosal barrier cues. may be both
grimacing against acid. physiological and
Gastromucosal psychological and
prostaglandins may be use in
V/S taken as increase the conjunction with
follows barrier’s resistance verbal cues to
to ulceration. The evaluate extent and
T: 37.3˚C integrity of the severity of the
P: 89 barrier is enhanced problem.
R: 19 by the rich blood Provide small Food has an acid-
BP: 110/ 80 supply of the frequent meals. neutralizing effect
mucosa of the and dilutes the
stomach and gastric contents.
duodenum. Small meals
prevent distention
and the release of
gastrin.
Identify and limit Specific foods that
foods that create cause distress vary
discomfort. among individuals.
Spicy foods,
alcohol, and coffee
can precipitate
Student Nurses’ Community
dyspepsia.
Reduces joint
Assist with active and stiffness,
passive range of minimizing pain
motion exercises. and discomfort.
Provide frequent oral Halitosis from
care and comfort stagnant oral
measures including secretions is
back rub and position unappetizing and
change. can aggravate
nausea.
Collaborative
Provide and
implement dietary Client may receive
modifications. nothing by mouth
initially. When oral
intake is allowed,
food choices
depend on the
diagnosis and
etiology of the
Use regular than bleeding.
skim milk, if milk is Fat in regular milk
allowed. may decreases
gastric secretions.
The calcium and
protein content
especially in skim
milk increases
secretions.
Administer Helps relive acute or
medications as severe pain.
indicated such as
analgesics.