This care plan for Gastroenteritis focuses on the initial management in a non-acute care setting. F. actors that may affect the functionality of the gastrointestinal tract include age, anxiety levels, intolerances, nutrition and ingestion, mobility or immobility, malnutrition, medications, and recent or coming surgical procedures. Assess the clients history of bleeding or coagulation disorders.Determine the clients history of cancer, coagulation abnormalities, or previous GI bleeding to determine the clients risk of bleeding issues. These contents can range from feces from a more distal location of perforation to extremely acidic gastric contents in more proximal bowel perforation. To replace losses and improve gastrointestinal function. Available from: Lewiss Medical-Surgical Nursing. The bypass involves . Choices A, B, and D are proper interventions in providing pain control. Meanwhile, diarrhea is when there is an increased frequency of bowel movement, altered consistency of stool, and increased amount of stool. Since analgesics can conceal symptoms and indications, they may be withheld throughout the first diagnostic process. Assist the healthcare provider in treating underlying issues.Collaboration with the healthcare provider is necessary to determine the root cause of decreased fluid volume and bleeding. Keep NPO and consider a nasogastric tube. Learn how your comment data is processed. 3. Review and Administer prescribed medications.Examine the clients prescription, over-the-counter (OTC), herbal, and nutritional supplements to find any substances that might affect fluid and electrolyte balance or may be a cause of GI bleeding. NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023The definitive guide to nursing diagnoses is reviewed and approved by NANDA International. Discuss with the patient the dosage, frequency, and potential negative effects of the medications. C. 40 and 60 years. Its important to also assess the exact location of abdominal pain. St. Louis, MO: Elsevier. gram-negative bacteria. Nursing Diagnosis: Acute Pain related to tissue trauma, chemical irritation of the parietal peritoneum, and abdominal distension secondary to bowel perforation as evidenced by muscle guarding, rebound tenderness, verbalization of pain, distraction behavior, facial mask of pain, and autonomic or emotional responses (anxiety). Keep an eye out for any indications of active bleeding, such as changes in the vital signs (increased heart rate, lowered blood pressure), bruises on the flanks, frank blood coming through an ostomy or NG tube, etc. Encourage adequate hydration (drink water) Encourage good oral hygiene. She found a passion in the ER and has stayed in this department for 30 years. Laxatives soften stool and allow for easier defecation. Based on the assessment data, the patients nursing diagnoses may include the following: Main Article: 5 Peptic Ulcer Disease Nursing Care Plans. A number of risk factors may increase the risk of developing bowel perforation including: The abdominal cavity, which encloses a number of internal organs, is normally sterile. 1. Large gastric suction losses may occur, and the intestine and peritoneal space may sequester a significant amount of fluid (ascites). Intestinal perforation, defined as a loss of continuity of the bowel wall, is a potentially devastating complication that may result from a variety of disease processes. Patient will be able to maintain adequate fluid volume as evidenced by stable vital signs, balanced intake and output, and capillary refill <3 seconds. What are the signs and symptoms of bowel perforation? Includes: appendectomy, gastroenteritis, inflammatory bowel disease, live cirrhosis, and more. 5. This lowers the danger of contamination and gives the chance to assess the healing process. 4. If left untreated, it can result in internal bleeding, peritonitis, permanent damage to the intestines, sepsis, and death. Administer antibiotics as ordered. Assess the extent of nausea, vomiting, and limited food and fluid intake. Inadequate participation in care planning, Inaccurate follow-through of instructions, Development of a preventable complication. Desired Outcome: The patient will practice appropriate behaviors to assist with resolution of condition. 2. Monitor for signs and symptoms of infection, such as fever and elevated heart rate. Encourage patient to eat regular meals in a. Abdominal surgery recently or in the past, Trauma to the pelvis or abdomen, such as from an accident, Scar tissue formation, typically from a prior operation, in the pelvic area, Being assigned female at birth because a surgery can more readily injure the colon, Hemodynamic instability leading to hypoperfusion, Infection such as peritonitis, local abscess formation, or systemic bacteremia, Fistula formation, bowel obstruction, and hernia formation secondary to postoperative adhesions, The patient will achieve timely healing and be free of fever and purulent drainage or erythema. This condition can be caused by injury, trauma, or an underlying health condition, including: It is vital to seek medical care when clinical signs of bowel perforation occur. Our website services and content are for informational purposes only. Hemoglobin is the oxygen-carrying component of blood while hematocrit reflects blood volume. The nurse can monitor the vital signs of the patient, especially alterations in the blood pressure and pulse rate which may indicate the presence of bleeding. Identify current medications being taken by the patient. These will lessen fluid loss and neutralize stomach acid hopefully preventing further irritation of the GI mucosa. All-in-One Nursing Care Planning Resource E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental HealthIncludes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. However, in the case of bowel perforation, contents of the bowel may leak out through the hole in its wall. Assess complaints of pain, pain response, pain characteristics. Around 2% of colonoscopies are reported to result in perforations generally, with greater rates during the procedure necessitating therapeutic measures. Here are four (4) nursing care plans (NCP) for Gastroenteritis: Learn about the best nursing care plans and nursing diagnosis for treating hemorrhoids in this comprehensive guide. The treatment is symptomatic, although cases of bacterial and parasitic infections require antibiotic therapy. Anna Curran. Intestinal Perforation - StatPearls - NCBI Bookshelf Bloating, vomiting, abdominal cramping, watery stool, and constipation occur as food and fluid are prevented from passing through the intestines. Patient Assessment Assess tissue perfusion. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Ensure infection control precautions are followed.Interventions that can help reduce infection in patients with bowel perforation include meticulous hand hygiene before and after handling the patient, the surgical site, and IV sites or catheters. 4. B. Clostridium difficile D. 60 and 80 years. Her nursing career has brought her through a variety of specializations, including medical-surgical, emergency, outpatient, oncology, and long-term care. Maintain NPO by intestinal or nasogastric aspiration. Emphasize the value of medical follow-up. Thank you Marianne! Symptoms of bowel perforation may include the following: When peritonitis occurs secondary to bowel perforation, the abdomen becomes tender and painful on palpation or when the patient moves. 1. There are three major causes of peptic ulcer disease: infection with H. pylori, chronic use of NSAIDs, and pathologic hypersecretory disorders (e.g., Zollinger-Ellison syndrome). In: StatPearls [Internet]. 2. Nursing interventions are also implemented to prevent and mitigate potential risk factors. Nursing care plans: Diagnoses, interventions, & outcomes. Assess vital signs.Recognize persistent hypotension, which may lead to abdominal organ hypoperfusion. 3. 3. To prevent the occurrence of dehydration. Gastric Perforation - StatPearls - NCBI Bookshelf Encourage patient to eat regularly spaced meals in arelaxed atmosphere; obtain regular weights and encouragedietary modications. This provides baseline knowledge to allow the patient to make educated decisions. The Dr. Now Diet and How to Follow It | U.S. News 1 - 4, 6 Adhesions resulting from prior abdominal surgery are the predominant cause of . Viral gastroenteritis also called stomach flu is a very contagious form of this disease. Healthline. The most common site for peptic ulcer formation is the: A. Duodenum. A hole in your stomach or small intestine can leak food or digestive fluids into your abdomen. The nurse can also provide non-pharmacologic pain management interventions such as relaxation techniques, guided imagery, and appropriate diversional activities to promote distraction and decrease pain. Desired Outcome: The patient will maintain a normal weight and a positive nitrogen balance. Main Article: 5 Peptic Ulcer Disease Nursing Care Plans The goals for the patient may include: Relief of pain. Bowel perforation results from insult or injury to the mucosa of the bowel wall resulting from a violation of the closed system. Peptic ulcer disease may be caused by which of the following? Nursing care planning goals of gastroesophageal reflux disease(GERD)involves teaching the patient to avoid situations that decrease lower esophageal sphincter pressure or cause esophageal irritation. Assessment of the characteristics of the vomitus. However, common signs and symptoms include severe abdominal pain, bloating, nausea and vomiting, fever, chills, and a rapid heartbeat. As tolerated, advance the patients diet. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions will be directed at the prevention of signs and symptoms. Gastrointestinal perforation is a hole in the wall of the stomach, small intestine, or large bowel. Assess what patient wants to know about the disease, andevaluate level of anxiety; encourage patient to expressfears openly and without criticism. Monitor fluid volume status by measuring urine output hourly and measure nasogastric and other bodily drainage. Diverticulitis Pathophysiology for nursing students and nursing school, Imbalanced Nutrition: Less Than Body Requirements, Conjunctivitis Nursing Diagnosis and Nursing Care Plan, Pancreatic Cancer Nursing Diagnosis and Nursing Care Plan. This can cause leakage of gastric acid or stool into the peritoneal cavity. Even though bowel sounds are typically absent, intestinal inflammation and irritation can also cause diarrhea, decreased water absorption, and intestinal hyperactivity. Dysfunctional gastrointestinal motility can be defined as the impairment of the digestive tract that results in ineffective gastric activity. As shock becomes refractory, later symptoms include chilly, clammy, pale skin and cyanosis. Intestinal Obstruction: Evaluation and Management | AAFP Here are five (5) nursing care plans (NCP) for peptic ulcer disease: Hospitalization may be needed for clients who experience severe dehydration as a result of the vomiting and diarrhea. Assess the patients level of pain and pain characteristics.Patients typically describe a worsening of abdominal pain and distention with bowel perforation. The most common causes of acute intestinal obstruction include adhesions, neoplasms, and herniation (). Peptic ulcer disease may occur in both genders and in all ages. Diet modification: small frequent feedings, bland meals, avoidance of caffeine, spicy, citrus, dairy products, and carbonated products. Nursing Diagnosis: Dysfunctional Gastrointestinal Motility related to limited fluid intake and sedentary lifestyle as evidenced by infrequent passage of stool, straining upon defecation, passage of dry, hard stool. Men are more likely than women to have vascular disorders and diverticulosis, which makes LGIB more prevalent in men. As an Amazon Associate I earn from qualifying purchases. B. Bowel Perforation. Management of this disorder includes temporary cessation of diet and intravenous nutrient supplementation. The ligament of Treitz sometimes referred to as the suspensory ligament of the duodenum, is the anatomical marker that delineates the upper and lower bleeding. Administer medications as ordered: antidiarrheals. PDF Dislodged Gastrostomy Tubes: Preventing a Potentially Fatal Complication 2. 2. 2. Nursing care plans: Diagnoses, interventions, & outcomes. Helicobacter pylori is considered to be the major cause of ulcer formation. 2. Spontaneous perforation of the stomach is an uncommon event mainly seen in the neonatal period, the first few days of life, as a cause of pneumoperitoneum. It is vital to determine the source and cause of bleeding and intervene. Diarrhea is often accompanied by urgency, anal discomfort, and incontinence. F A Davis Company. Nursing Care Plans and Interventions 1. In some cases, there may be a pain-free period followed by worsening pain due to decompression just after perforation. Assess the patients understanding of the current condition.This will help determine the need to provide more information about the patients condition and the topics that need to be addressed. Nursing Diagnosis: Dysfunctional Gastrointestinal Motility related to gastroenteritis as evidenced by frequency of stools, abdominal pain, and urgency. Give regular oral care. Nursing Diagnosis: Dysfunctional Gastrointestinal Motility related to limited fluid intake and sedentary lifestyle as evidenced by infrequent passage of stool, straining upon defecation, passage of dry, hard stool. Evaluate the patients abdomen periodically for softening, the resumption of regular bowel noises, and the passing of flatus. Insert an indwelling urinary catheter and monitor intakeand output; insert and maintain an IV line for infusinguid and blood. Fluids are needed to maintain the soft consistency of fecal mass. The sixteenth edition includes the most recent nursing diagnoses and interventions from NANDA-I 2021-2023 and an alphabetized listing of nursing diagnoses covering more than 400 disorders. Any bleeding that takes place in the gastrointestinal tract is referred to as gastrointestinal (GI) bleeding. If the condition does not improve, a surgical intervention called fundoplication may be done. These complications include hemorrhage(cool skin. Like all body systems and organs, the gastrointestinal tract can also be affected by internal and external factors. This reduces guarding and muscle tension, which might reduce movement-related pain. Category: Gastrointestinal Care Plans | NurseTogether The gastrointestinal tract is the system responsible for converting food taken in through the mouth into the energy and nutrients that the human body needs. A guide to nursing diagnosis for pancreatitis, including the different types of nursing care plans, symptoms, causes, and treatments. Colloids (plasma, blood) increase the osmotic pressure gradient, which aids in the movement of water back into the intravascular compartment. Certain drugs can slow down peristalsis and contribute to constipation, i.e. Desired Outcome: The patient will pass formed stool no more than thrice per day. Gastrointestinal Care Plans - Nurseslabs 1. NurseTogether.com does not provide medical advice, diagnosis, or treatment. Early detection and treatment of developing complications can help prevent progression to severe illness and injury. Gastrointestinal Care Plans Care plans covering the disorders of the gastrointestinal and digestive system. In addition to the typical symptoms of a bowel perforation, symptoms of peritonitis might include: The underlying causes of bowel perforation can be categorized based on their anatomic location, however many etiologies are overlapping, and these may include: Bowel perforation can also be caused by medical procedures involving the abdomen which may include: Bowel perforation in children is most likely to occur after abdominal trauma. Desired Outcome: The patient will maintain passage of soft, formed stool at a regular frequency. 2. 3. Get a better understanding of this condition and how to provide the best care for patients. Peristalsis may be increased, decreased, or may even be absent. Food-borne gastroenteritis or food poisoning is associated with bacteria strains such as Escherichia coli, Clostridium, Campylobacter, and salmonella. Excess Fluid Volume Nursing Diagnosis and Nursing Care Plan, Pulmonary Embolism Nursing Diagnosis and Nursing Care Plan. Please follow your facilities guidelines, policies, and procedures. A variety of bacteria, viruses, and parasites are associated with gastroenteritis. Neonatal gastrointestinal perforation is a common condition carrying a mortality of 17-60%.1 Clinical suspicion is supported by radiological signs, which may be subtle and must be sought specifically. Encourage increase fluid intake of 1.5 to 2.5 liters/24 hours plus 200 ml for each loose stool in adults unless contraindicated.Increased fluid intake replaces fluid lost in liquid stools. The nurse auscultated over the stomach to confirm correct placement before administering medication. Assess wound healing.Following surgical intervention, the nurse should monitor incisions for any redness, warmth, pus, swelling, or foul odor that signals an abscess or delayed wound healing. The stomach showed no attachment to the abdominal wall. Includes: appendectomy, gastroenteritis, inflammatory bowel disease, live cirrhosis, and more. Complete blood count, basic metabolic panel, and inflammatory markers should also be reviewed to assess signs of infection and determine liver and kidney function. Ackley and Ladwigs Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning CareWe love this book because of its evidence-based approach to nursing interventions. Challenge of Assessing and Diagnosing Acute Abdomen in - Medscape To provide baseline data and determine is fluid and nutrient supplementation is required. Elsevier/Mosby. Please follow your facilities guidelines, policies, and procedures. Assist the patient in understanding the condition and factors that help or aggravate it. Ask the client about arecent history of drinking contaminated water, eating food inadequately cooked, and ingestion of unpasteurized dairy products:Eating contaminated foods or drinking contaminated water may predispose the client to intestinal infection.
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