NURSING PROCESS RECORD

NAME CODE: Mr. Jones

MEDICAL DIAGNOSIS: Gastric Ulcer

Nursing Diagnosis: (00132) Acute Pain related to the effect of gastric acid secretion on damaged tissue/gastric ulceration.
NANDA Definition: Unpleasant sensory and emotional experience associated with 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 with a duration of
less than 3 months.
CUES (Defining Characteristics) OUTCOMES INTERVENTIONS EVALUATION
Subjective: NOC 1: Client Satisfaction: Pain NIC 1: Pain Management Day 1:
-Complaints of burning abdominal pain Management NOC 1- 1 Not satisfied at all
from epigastric to abdominal region at a [301601] Pain Controlled Activities:  Client still in pain
scale of 7/2. 1- Not at all satisfied  Perform a comprehensive assessment  110 bpm
-Daughter mention patient has been 2- Somewhat satisfied of pain to include location,  92% O2 Sat
enduring pain for 2 days. 3- Moderately satisfied characteristics, onset/duration,  80/60 mmHg
4- Very satisfied frequency, quality, intensity or  22 cpm
Objective: 5- Completely satisfied severity of pain, and precipitating
PR: 100 bpm (upon admission) factors
RR: 26 cpm NOC 2: Pain Control  Assure patient attentive analgesic
BP: 90/50 mmHg (upon admission) [160511] Reports pain controlled care
O2 Sat: 95% (upon admission) 1- Never demonstrated  Use therapeutic communication NOC 2- no data available
2- Rarely demonstrated strategies to acknowledge the pain
Lab results: 3- Sometimes demonstrated experience and convey acceptance of
H. Pylori test: Positive 4- Often demonstrated the patient’s response to pain
EGD: Positive w/ gastric ulceration 5- Consistently demonstrated  Explore patient’s knowledge and
beliefs about pain
 Consider cultural influences on pain
response
 Explore with patient the factors that
improve/worsen pain
 Evaluate, with the patient and the
health care team, the effectiveness of
past pain control measures that have
been used
 Assist patient and family to seek and
 provide support
 Utilize a developmentally appropriate
assessment method that allows for
monitoring of change in pain and that
will assist in identifying actual and
potential precipitating factors (e.g.,
flow chart, daily diary)
 Determine the needed frequency of
making an assessment of patient
comfort and implement monitoring
plan
 Control environmental factors that
may influence the patient’s response
to discomfort (e.g., room temperature,
lighting, noise)
 Reduce or eliminate factors that
precipitate or increase the pain
experience (e.g., fear, fatigue,
monotony, and lack of knowledge)
 Consider the patient’s willingness to
participate, ability to participate,
preference, support of significant
others for method, and
contraindications when selecting a
pain relief strategy
 Explore patient’s current use of
pharmacological methods of pain
relief
 Teach about pharmacological
methods of pain relief
 Encourage patient to use adequate
pain medication
 NURSING PROCESS RECORD
NAME CODE: Mr. Jones
MEDICAL DIAGNOSIS: Gastric Ulcer

Nursing Diagnosis: (00146) Anxiety related to acute illness

NANDA Definition: Vague, uneasy feeling of discomfort or dread accompanied by an autonomic response (the source is often nonspecific or unknown to the individual);
a feeling of apprehension caused by anticipation of danger. It is an alerting sign that warns of impending danger and enables the individual to take measures to deal with
that threat.
CUES (Defining Characteristics)
Subjective:
-Complaints of burning abdominal pain
from epigastric to abdominal region at a reduce anxiety
scale of 7/2.
-Daughter mention that patient only
prompted to seek consultation because
of a sudden episode of hematemesis.
Objective:
Increased heart rate (100 bpm)
Increases Respiratory rate (26 cpm)
Decreased blood pressure
( 90/50 mmHg)
O2 Sat: 95%
OUTCOMES
NOC 1: Anxiety Self-Control
[140207] Uses relaxation techniques to
1- Never demonstrated
2- Rarely demonstrated
3- Sometimes demonstrated
4- Often demonstrated
5- Consistently demonstrated
INTERVENTIONS EVALUATION
NIC 1: Relaxation Therapy Day 1:
NOC 1- 1 Never demonstrated
Activities:  Client still in pain
 Describe the rationale for relaxation  Client vomited
and the benefits, limits, and types of  Nailbeds are pail CTR: 5 seconds
relaxation available (e.g., music,  110 bpm
meditation, rhythmic breathing, jaw  92% O2 Sat
relaxation, and progressive muscle  80/60 mmHg
relaxation)  22 cpm
 Screen for current decreased energy
level, inability to concentrate, or other
concurrent symptoms that may
interfere with cognitive ability to
focus on relaxation technique
 Determine whether any relaxation
intervention in the past has been
useful
 Consider the individual’s willingness
to participate, ability to participate,
preference, past experiences, and
contraindications, before selecting a
specific relaxation strategy
 Provide detailed description of
chosen relaxation intervention
 Suggest that the individual assume a
comfortable position, with
 unrestricted clothing and eyes closed
 Individualize the content of the
relaxation intervention (e.g., by
asking for suggestions of changes)
 Elicit behaviors that are conditioned
to produce relaxation, such as deep
breathing, yawning, abdominal
breathing, or peaceful imaging
 Invite the patient to relax and let the
sensations happen
 Use soft tone of voice with a slow,
rhythmical pace of words
 Demonstrate and practice the
relaxation technique with the patient
 Encourage return demonstrations of
techniques, if possible
 Anticipate the need for the use of
relaxation
 Use relaxation as an adjuvant strategy
with pain medication or in
conjunction with other measures, as
appropriate
 Evaluate and document the response
to relaxation therapy

NAME CODE: Mr. Jones
MEDICAL DIAGNOSIS: Gastric Ulcer
Nursing Diagnosis: (00028) Risk for deficient fluid volume related to gastrointestinal bleeding and vomiting
NANDA Definition: Susceptible to experiencing decreased intravascular, interstitial, and/or intracellular fluid volumes, which may compromise health.
CUES (Defining Characteristics)
Subjective:
-Complaints of burning abdominal pain
from epigastric to abdominal region at a strategies
scale of 7/2.
-Daughter mention that patient only
prompted to seek consultation because
of a sudden episode of hematemesis.
Objective:
Increased heart rate (100 bpm)
Increases Respiratory rate (26 cpm)
Decreased blood pressure
( 90/50 mmHg)
O2 Sat: 95%
Coffee ground vomitus
Lab results:
FOBT: positive
EGD: positive w/ gastric ulcerations
Decreased RBC
Decreased Hemoglobin
Decreased Hematocrit
NURSING PROCESS RECORD
OUTCOMES INTERVENTIONS EVALUATION
NOC 1: Risk Control NIC 1: Bleeding Reduction: Day 1:
[190204] Develops effective risk control Gastrointestinal NOC 1- 1 Never demonstrated
 Client still in pain
1- Never demonstrated Activities:  Client vomited
2- Rarely demonstrated  Evaluate patient’s psychological  Nailbeds are pail CTR: 5 seconds
3- Sometimes demonstrated response to hemorrhage and  110 bpm
4- Often demonstrated perception of events  92% O2 Sat
5- Consistently demonstrated  Maintain a patent airway, if necessary  80/60 mmHg
 Monitor determinants of tissue  22 cpm
oxygen delivery (e.g., PaO2, SaO2, and
hemoglobin levels and cardiac
output), if available
 Monitor for signs and symptoms of
persistent bleeding (e.g., check all
secretions for frank or occult blood)
 Monitor fluid status, including intake
and output, as appropriate
 Administer IV fluids, as appropriate
 Monitor for signs of hypovolemic
shock (e.g., decreased blood pressure,
rapid thready pulse, increased
respiratory rate, diaphoresis,
restlessness, cool clammy skin)
 Measure abdominal girth, as
appropriate
 Hematest all excretions and observe
for blood in emesis, sputum, feces,
urine, NG drainage, and wound
 drainage, as appropriate
 Document color, amount, and
character of stools
 Monitor coagulation studies and
complete blood count (CBC) with
white blood count (WBC) differential,
as appropriate
 Avoid administration of
anticoagulants
 Assess the patient’s nutritional status
 Establish a supportive relationship
with the patient and family
 Instruct the patient and family on
activity restriction and progression
 Instruct the patient and/or family on
procedures (e.g., endoscopy, sclerosis,
and surgery), if appropriate
 Instruct the patient and/or family on
the need for blood replacement, as
appropriate
 Instruct the patient and/or family to
avoid the use of antiinflammatory
medications (e.g., aspirin and
ibuprofen)