VII.

NCP AND CASE STUDY

assessment Nursing diagnosis inference planning intervention rationale Evaluation

Subjective cues: Fluid Volume, Peptic ulcers After 30 mins of nursing Note Helpful in After effective nursing
deficient(isotonic intervention the patient
) r/t to Active will: characteristic determining intervention the patient
fluid volume  Learn the s of vomitus cause of gastric was able to:
loss(hemorrhage) Gastric disease process or drainage distress  Demonstrate
Objective cues: erosion
 Decreased improved fluid
urine output After an effective Changes in Bp balance as
 UO- 50 ml nursing intervention the Mon itor V/S and pulse may evidence by
 Restless Epigastric patient will:
 Delayed  Demonstrate be used for individually
capillary refill mucosal improved fluid rough estimate adequate
 Weight loss tears (Mallory balance as of blood loss urinary output
-Weiss
evidence by
individually with normal
syndrome) adequate Provides specific gravity,
urinary output guidelines for stable V/S,
with normal
specific gravity, Monitor I and fluid moist mucous,
Hematemesis
stable V/S, O and replacement good skin
moist mucous, correlate turgor, prompt
good skin
turgor, prompt weight capillary refill.
capillary refill. changes.
Fluid volume
Measure
deficient
blood/ fluid Potential exits
losses via for
emesis. overtransfusio
Gastric n of fluids, esp.
suction when volume
expanders are
Keep given before
accurate blood
record of transfusion
subtotals of
solution/ Activity/
blood vomiting
products increases intra
during abdominal
replacement pressure and
therapy. can predispose
to further
Maintain bed bleeding
rest; prevent
vomiting and
straining at More easily
stool digested and
reduce risk of
added
irritation to
inflamed
 tissues.
Caffeine and
Provide carbonated
clear/ band beverages
fluids when stimulate HCL
intake is production,
resumed. possibly
Avoid potentiating
caffeinated rebleeding
and
carbonated
beverages
Name classification action indication contraindication Adverse effect Nursing
consideration
Omeprazole Proton pump Gastric acid pump Tx of active With Headache, Administer before
inhibitor inhibitor.blocks duodenal ulcer hypersensitivity dizziness, meals.
the final acid Tx of active to omeprazole diarrhea, nausea Administer
production benign gastric Use catiously with and vomiting antacid with if
ulcer pregnancy and needed.
lactating

Losartan Anti hypertensive Blocks the Tx of HPN With Headache, Administer

vasoconstriction Tx of diabetic hypersensitivity dizziness, without regards
effect of rennin- nephropathy to losartan, hypotension, of meal
angiotensin. Reduction of the pregnancy, abdominal pain, Monitor BP
risk of CVA lactation nausea and
Use catiously with vomiting
hepatic or renal
impairment