Nursing Care Plan for gastritis - Nursing Diagnosis : Acute Pain
Gastritis is an inflammation of the lining of the stomach, and has many possible causes. The main acute causes are excessive alcohol consumption or prolonged use of nonsteroidal anti-inflammatory drugs (also known as NSAIDs) such as aspirin or ibuprofen. Sometimes gastritis develops after major surgery, traumatic injury, burns, or severe infections. Gastritis may also occur in those who have had weight loss surgery resulting in the banding or reconstruction of the digestive tract. Chronic causes are infection with bacteria, primarily Helicobacter pylori, chronic bile reflux, and stress; certain autoimmune disorders can cause gastritis as well. The most common symptom is abdominal upset or pain. (wikipedia)
Acute Pain
Pain is whatever the experiencing person says it is, existing whenever the person says it does (McCaffery, 1968); an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain) sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than less than 6 months.
Defining Characteristics:
Subjective
Pain is always subjective and cannot be proved or disproved. A client's report of pain is the most reliable indicator of pain (Acute Pain Management Guideline Panel, 1992). A client with cognitive ability who can speak or point should use a pain rating scale (e.g., 0 to 10) to identify the current level of pain intensity (self-report) and determine a comfort/function goal (McCaffery, Pasero, 1999).
Objective
Expressions of pain are extremely variable and cannot be used in lieu of self-report. Neither behavior nor vital signs can substitute for the client's self-report (McCaffery, Ferrell, 1991, 1992; McCaffery, Pasero, 1999). However, observable responses to pain are helpful in clients who cannot or will not use a self-report pain rating scale. Observable responses may be loss of appetite and inability to deep breathe, ambulate, sleep, or perform activities of daily living (ADLs). Clients may show guarding, self-protective behavior, self-focusing or narrowed focus, distraction behavior ranging from crying to laughing, and muscle tension or rigidity. In sudden and severe pain, autonomic responses such as diaphoresis, blood pressure and pulse changes, pupillary dilation, or increases or decreases in respiratory rate and depth may be present.
Nursing Diagnosis for Gastritis : Acute Pain related to inflammation of the mucosal lining of the stomach (gastric)
Goal: Pain is reduced with no inflammation or irritation of the gastric mucosa
Outcomes:
- Pain scale is reduced
- Do not feel pain in the epigastric.
- Not grimace (no abdominal tenderness)
Gastritis Nursing Interventions and Rational:
1. Record complaints of pain, including the location, duration, intensity (scale of 0-10)
R /: Pain is not always there, but if there is to be compared with the previous patient's symptoms of pain, which can help diagnose the etiology and occurrence of bleeding complications.
2. Review the factors that increase or decrease pain.
R /: Assist in making diagnoses and treatment needs.
3. Give food a little but often as an indication for patients.
R /: Food has the effect of neutralizing acid, also destroy the gastric contents. Eating little to prevent distension.
4. Assistive range of motion exercises active / passive.
R /: Reduce joint stiffness, pain minimize discomfort.
5. Provide frequent oral care and comfort measures (back massage, change of positions).
R /: Bad breath due to retained secretions, causing no appetite and can increase nausea. Gingivitis and dental problems can be improved.
6. Give medications as indicated.
R /: Lowering the acidity of gastric absorption or by neutralizing chemical.
Gastritis - Definition, Classification, Pathophysiology and Prevention
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