X.

Nursing Care Plan (NCP)

ASSESSMENT
SUBJECTIVE:
Napakasakit
ng tiyan ko
(Im having
severe
stomach pain)
as verbalized
by the patient.

OBJECTIVE:

Abdominal
guarding
Rigid body
posture
Facial
grimacing
9/10 Pain
Scale
V/S taken as
follows
T: 37.3C
P: 89

DIAGNOSIS

Background
Knowledge

PLANNING

INTERVENTION

Acute pain
related to
chemical
burn of
gastric
mucosa, oral
cavity and
physical
response
such as flex
muscle
spasm in the
stomach wall
(Disease
Process) as
manifested
by 9/10 Pain
Scale and
Abdominal
guarding

Acid, pepsin,
and
helicobacter
infection play
an important
role in the
development
of gastric
ulcers. The
gastric
mucosal
barrier
overlies the
epithelium.
The secretion
of mucus and
bicarbonate
provides a
first line
defense in
maintaining a
near-normal
pH on the
gastric
epithelium
and protects
the mucosal
barrier
against acid.
Gastromucosa

After 4 hours
of nursing
interventions
and health
teaching, the
Patient
verbalize
relief of pain
and
demonstrate
relaxed body
posture and
be able to
sleep or rest
properly.

Independent
Note reports of
pain, including
location,
duration, and
intensity (0-10
scale).

Review factors
that aggravate
or alleviate
pain.

Note nonverbal
pain cues.

RATIONALE

Pain is not
always
present,
should be
compared
with patients
previous pain
symptoms.
The
comparison
may assist in
diagnosis of
etiology of
bleeding and
development
of
complications.
Helpful in
establishing
diagnosis and
treatment
needs.
Non-verbal
cues may be
both
physiological
and
psychological

EVALUATION
After 4 hours
of nursing
interventions
and health
teaching, the
Patient was
able to
verbalized
relief of pain
and
demonstrate
relaxed body
posture and be
able to sleep
or rest
properly.

R: 19
BP: 110/ 80

l
prostaglandin
s increase the
barriers
resistance to
ulceration.
The integrity
of the barrier
is enhanced
by the rich
blood supply
of the mucosa
of the
stomach and
duodenum.

Provide small
frequent meals.

Identify and
limit foods that
create
discomfort.

Assist with
active and
passive range
of motion
exercises.
Provide
frequent oral
care and
comfort
measures
including back
rub and
position
change.

Collaborative
Provide and
implement
dietary

and may be
use in
conjunction
with verbal
cues to
evaluate
extent and
severity of the
problem.
Food has an
acidneutralizing
effect and
dilutes the
gastric
contents.
Small meals
prevent
distention and
the release of
gastrin.
Specific foods
that cause
distress vary
among
individuals.
Spicy foods,
alcohol, and
coffee can
precipitate
dyspepsia.
Reduces joint
stiffness,
minimizing
pain and
discomfort.

modifications.

Use regular
than skim milk,
if milk is
allowed.

Administer
medications as
indicated such
as analgesics.

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.
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.