Sunday, November 4, 2012

Risk for Ineffective Tissue Perfusion - NCP Gastritis

Nursing Care Plan for Gastritis

Gastritis is an inflammation of the stomach lining. 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.

In some cases, the stomach lining may be "eaten away," leading to sores (peptic ulcers) in the stomach or first part of the small intestine. Gastritis can occur suddenly (acute gastritis) or gradually (chronic gastritis). In most cases, gastritis does not permanently damage the stomach lining.

Risk Factors:
  • Infection with H. pylori
  • Acquired immunodeficiency syndrome (AIDS)
  • Any condition that requires relief from chronic pain using NSAIDS, such as chronic low back pain, fibromyalgia, or arthritis
  • Alcoholism
  • Cigarette smoking
  • Older age
  • Herpes simplex virus or cytomegalovirus
  • Inflammatory bowel disease

Signs and Symptoms:

The most common symptoms of gastritis are stomach upset and pain. Other possible symptoms include:
  • Indigestion (dyspepsia)
  • Heartburn
  • Abdominal pain
  • Hiccups
  • Loss of appetite
  • Nausea
  • Vomiting, possibly of blood or material that looks like coffee grounds
  • Dark stools

Risk for ineffective Tissue Perfusion - Nursing Care Plan Gastritis



Nursing Diagnosis: Risk for Ineffective Tissue Perfusion related to Hypovolemia

Nursing Intervention:

1. Investigate changes in level of consciousness, complaining of dizziness / headaches.
Rationale: The change may indicate inadequate cerebral perfusion as a result of artery blood pressure.

2. Investigate complaints of chest pain
Rationale: May indicate cardiac ischemia in relation to decreased perfusion.

3. Assess skin to cold, pale, sweating, slow capillary refill and peripheral pulses are weak.
Rational: Sympathetic Vasoconstriction is a response to the decline in circulating volume and / or can occur as a side effect of vasopressin administration.

4. Record the output of urine specific gravity and
Rationale: Decreased systemic perfusion can lead to ischemia / renal failure manifested by decreased urine output.

5. Record report abdominal pain, particularly sudden, severe pain or pain spreading to the shoulders.
Rationale: Pain caused by gastric ulcers are often lost after acute hemorrhage due to buffer the effects of the blood. Severe pain persists or suddenly can show respect to ischemia vasokinstriksi therapy.

6. Observation for pale skin, redness, massage with oil. Change positions frequently
Rational: disturbances in the peripheral circulation increases the risk of skin damage.

collaboration
7. Provide supplemental oxygen as indicated
Rational: treat hypoxemia and lactic acidosis during acute hemorrhage.

8. Give IV fluids as indicated
Rational: to maintain circulating volume and perfusion.

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