7 Nursing care plans for patient who has malignant neoplasm of stomach?

Assessment Subjective: Patient report “he has abdominal pain” Objective: Grimacing Subjective: Patient report that

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“he is vomited after each meal”. Objective: Pale, dry skin Nursing diagnosis Pain related to the presence of abnormal epithelial cells, nerve impulse disorders of the stomach evidenced by patient Reports of pain (5-10). goal Intervention Relief of pain 1.Administer analgesic agents as prescribed. Deficient Fluid Volume related to bleeding (loss of active) and hemoptysis. Vomiting with blood. Fluid requirements are met. Patient report pain less than 5 on a rating scale of 0 to 10. Vital signs within normal limits, good skin turgor, moist mucous membranes, the production of urine output is balanced, not vomiting blood and stools are not black rationale Patient reports decreased pain. 2.Assess frequency, intensity, and duration of pain to determine effectiveness of analgesic agent. 3.Work with patient to help manage pain by suggesting nonpharmacologic methods for pain relief, such as position changes, imagery, distraction, relaxation exercises, back rubs, massage, and periods of rest and relaxation. 1-Record the characteristics of vomiting and / or drainage. 2-Monitor vital signs; compared with normal results of client / previous. Measure blood pressure with sitting, sleeping, standing if possible. 3-Record patient’s physiological response to bleeding, such as mental changes, weakness, restlessness, anxiety, pale, sweaty, tachypnea, the increase in temperature. 4-Monitor input and output and connect them with changes in body weight. Measure blood loss / fluid through vomiting and defecation. 5-Maintain bed rest; prevent vomiting and stress at the time of defecation. Schedule of activities to provide a rest period without interruption. 6-Elevate head of bed for antacid drug administration. 7-Give fluid as indicated. evaluation Assist in distinguishing gastric distress. Postural hypotension showed decreased circulating volume. Worsening of symptoms may indicate the continued bleeding or inadequate fluid replacement. Provide guidelines for fluid replacement. Activities / vomiting increased intraabdominal pressure and can trigger further bleeding. Prevent gastric reflux and aspiration of antacids which can cause serious lung complications. Replacement fluid hypovolemia. It may be used when the infection causes chronic gastritis. A tool to determine the need for blood replacement and 8-Give antibiotics as indicate. Subjective: Objective: Ineffective tissue perfusion related to hypovolemia Maintain effective tissue perfusion 9-Supervise laboratory examination; e.g. Hb / Ht. 1.Monitor changes in level of consciousness, dizziness complaints / headaches. 2.Auscultation apical pulse. Guard heart rate / rhythm when there is a continuous ECG. 3.Assess the skin to cold, pale, sweating, slow capillary filling, and peripheral pulse is weak. 4.Note the report abdominal pain, especially sudden severe pain or pain spreading to shoulders. 5.Observations for pale skin, reddish. Massage with oil. Change positions frequently. 6.Collaboration: 7-Provide supplemental oxygen as indicated. 8-Give IV fluids as indicated oversee the effectiveness of therapy The change may indicate inadequate cerebral perfusion due to arterial blood pressure. Change dysrhythmias and ischemia can occur as a result of hypotension, hypoxia, acidosis, electrolyte imbalance, or cooling near the heart area. Vasoconstriction is a sympathetic response to the decline in circulation volume and / or may occur as a side effect of vasopressin. Pain caused by gastric ulcer, often disappear after acute hemorrhage due to buffer the effects of blood. Disturbances in peripheral circulation increases the risk of skin damage. Treat hypoxemia and lactic acidosis during acute hemorrhage. Maintain circulating volume and perfusion. Subjective: Objective: Tiredness; drowsiness; apathy; insufficient energy and impaired competence to maintain the usual level of Fatigue related to physiological condition, malnutrition, negative life event and sleep deprivation improved sense of energy. 1. To orient for more frequently rest throughout the day. 2. To recommend avoiding excessive physical effort, to not waste energy. 3. To monitor blood count to assess the presence of major anemia. 4. To refer for medical evaluation if necessary. promote rest and restore energy physical activity. Subjective: Objective: Pale, dry skin Poor muscle tone Unbalanced nutrition: less than the body Requirements, related to gastric injury. Patient displays nutritional ingestion sufficient to meet metabolic needs. 1. Assess the patient’s knowledge on the importance and benefits of maintaining the normal nutritional body requirements. Patient takes adequate amount of food with the appropriate calories. 2. Explain to the patient and significant others the importance of maintaining proper nutrition. 3.Suggest eating preferred and well tolerated by the patients, better food with high content of calories / protein. 4.Encourage small, frequent feedings of nonirritating food to decrease gastric irritation; encourage fluid consumption between meals rather than with meals. 5.Schedule rest periods before meals and open packages and cut up food for patient. 6.facilitate tissue repair by ensuring food supplement 8. Record intake, output, and daily weights. 9.Assess sign of dehydration (thirst, dry mucous membranes, poor skin turgor, tachycardia, deceased urine output). 10.Review results of daily laboratory studies to note any metabolic abnormalities (sodium, potassium, glucose, blood urea nitrogen). Risk of bleeding Risk of bleeding related to advanced gastric lesion Patient does not experience bleeding as evidenced by normal blood pressure, stable hematocrit and hemoglobin 11.Administer antiemetic agents as prescribed. 1.Monitor patient’s vital signs, especially BP and HR. Look for signs of orthostatic hypotension. 2.Evaluate the patient’s use of any medications that can affect hemostasis Patient shows no sign of bleeding. Maintained normal blood pressure, stable hematocrit and levels and desired ranges for coagulation profiles. (e.g, anticoagulants, salicylates, NSAIDs, or cancer chemotherapy). 3.Monitor platelet count and coagulation test results. hemoglobin levels and desired ranges for coagulation profiles. 4. Check stool and urine for occult blood. 5. Educate the patient about over-the-counter drugs and avoid products that contain aspirin or NSAIDs such as ibuprofen and naproxen. 6.Provide psychological and emotional support to the patient. Subjective: Objective: Impaired skin integrity related to low fluid intake and poor nutrition. Regains integrity of skin. 7. Keep in touch with blood transfusion center. 1-Assess changes in body temperature, specifically increased in body temperature. 2-Assess the patient’s level of distress. 3-Assess patient’s nutritional status; refer for a nutritional consultation and/or institute dietary supplements. 4-Monitor site of impaired tissue integrity at least once daily for color changes, redness, swelling, warmth, pain, or other signs of infection. 5-Provide tissue care as needed. 6- Monitor patient’s skin care practices, noting type of soap or other cleansing agents used, temperature of water, and frequency of skin cleansing. 7-Encourage a diet that meets nutritional needs. 8-Educate patient about proper nutrition, hydration, and methods to maintain tissue integrity. Demonstrates understanding of plan to heal skin and prevent injury. Describes measures to protect the skin. 9-Encourage use of pillows, foam wedges, and pressure-reducing devices.
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