AGUINALDO, SOPHIA KAYE M.

BSN III-E RLE GROUP 2

NURSING CARE PLAN

PEPTIC ULCER DISEASE

NURSING DIAGNOSIS

Acute pain related to hyperacidity secondary to irritation of gastric mucosa

Subjective Data:

- passage of black -tarry stools for almost 3 days

- almost “unbearable pain” after meal for the past 2 days
Objective Data:

- looked pale and afebrile

- vital signs were taken as follows:
HR- 102bpm
BP- 90/60 mmHg
RR- 21bpm
- Abdominal tenderness
- rebound tenderness present in epigastrium (Burning) with noticeable guarding behavior
on the area
- globularly enlarged

NURSING INFERENCE

Peptic ulcer disease is recurring formation of gastric and/or duodenal peptic ulcers. It is also a
condition in which painful sores or ulcer develops in the lining of the stomach or the first part of
the small intestine. The leading symptom is epigastric pain or epigastric discomfort.

NURSING GOAL

After 1-2 hours of nursing intervention, the patient will be able to:

1. Verbalize relief of pain.

AGUINALDO, SOPHIA KAYE M.
BSN III-E RLE GROUP 2
2. Demonstrate relaxed body posture and be able to sleep or rest appropriately.
NURSING INTERVENTIONS AND RATIONALE
Nursing Intervention
Independent:
1. Note reports of pain, including
location, duration, and intensity (0-10
scale).
2. Review factors that aggravate or
alleviate pain.
3. Identify and limit foods that create
discomfort such as spicy or
carbonated drink.
4. Encourage small, frequent meals.
5. Encourage patient to assume position
of comfort.
Collaborative:
1. Provide and implement prescribed
dietary modifications.
2. Administer medication as indicated.
Analgesics. e.g., morphine sulfate
Antacids
Anticholinergics, e.g., belladonna,
atropine
NURSING EVALUATION
After 1-2 hours of nursing intervention, the patient:
Rationale
Pain is not always present, but if present
should be compared with patient’s previous
pain symptoms. This comparison may assist
in diagnosis of etiology of bleeding and
development of complications.
Helpful in establishing diagnosis and
treatment needs.
Food has an acidic neutralizing effect and
dilutes the gastric contents.
Small meals prevent distension and the
release of gastrin.
Reduces abdominal tension and promotes
sense of control.
Patient may receive nothing by mouth (NPO)
initially. When oral intake is allowed, food
choices depend on the diagnosis.
May be narcotic to relieve acute or severe
pain and reduce peristaltic activity.
Note: Meperidine (Demerol) has been
associated with increased incidence of
nausea/vomiting.
Decrease gastric acidity by absorption or by
chemical neutralization. Evaluate choice of
antacid in regard to total health picture, e.g.,
sodium restriction
May be given at bedtime to decrease gastric
motility, suppress acid production, delay
gastric emptying, and alleviate nocturnal
pain associated with gastric ulcer.
AGUINALDO, SOPHIA KAYE M.
BSN III-E RLE GROUP 2
1. Verbalized relief of pain.
2. Demonstrated relaxed body posture and be able to sleep or rest appropriately.