NCP-Gastritis nursing care plan for nursing students heheheheheheheheheheheheheheh.docx

NCP

1. NURSING DIAGNOSIS: Ineffective Airway Clearance related to increased production of secretions, retained secretions, and thick, viscous secretions.
Assessment Planning Interventions Rationale Evaluation
Objected Data:
Labored breathing

VS Taken:
RR-29 cpm (labored
breathing)
02SAT- 86%
BP- 60/40 mmHg
T- 35.4
PR- 135 bpm
At the end of 8-hour
student-nurse client
interactions, client will
demonstrate behaviors
to improve airway
clearance.
INDEPENDENT:
1.Assess rate/depth of
respirations and chest
movement. Monitor for
signs of respiratory failure
(e.g., cyanosis and severe
tachypnea).
2.Auscultate lung fields,
noting areas of
decreased/absent airflow
and adventitious breath
sounds; e.g., crackles,
wheezes
3.Elevate head of bed, change
position frequently.
4.Assist client with frequent
deep-breathing exercises.
Demonstrate/help client
learn to perform activity;
e.g., splinting chest and
effective coughing while in
upright position.
5.Suction as indicated (e.g.,
frequent or sustained cough,
adventitious breath sounds,
desaturation related to
airway secretions).
INDEPENDENT:
Tachypnea, shallow respirations, and asymmetric chest
movement are frequently present because of discomfort
of moving chest wall and/or fluid in lung. When
pneumonia is severe, the client may require endotracheal
intubation and mechanical ventilation to keep airways
clear.
Decreased airflow occurs in areas consolidated with fluid.
Bronchial breath sounds (normal over bronchus) can also
occur in consolidated areas. Crackles, rhonchi, and
wheezes are heard on inspiration and/or expiration in
response to fluid accumulation, thick secretions, and
airway spasm/obstruction.
Keeping the head elevated lowers diaphragm, promoting
chest expansion, aeration of lung segments, and
mobilization and expectoration of secretions to keep the
airway clear
Deep brearhing facilitates maximum expansion of the
lungs/smaller airways. Coughing is a natural self-cleaning
mechanism, assisting the cilia to maintain patent airways.
Splinting reduces chest discomfort, and an upright
position favors deeper, more forceful cough effort. Note:
cough associated with pneumonias may last days to
weeks or even months.
Stimulates cough or mechanically clear airways in client
who is unable to do so because of ineffective cough or
decreased level of consciousness.
At the end of 8-hour
student-nurse client
interactions, client
was able to
demonstrate
behaviors to improve
airway clearance.

2. 6.Force fluids to atleast 3000
mL/day (unless
contraindicated, as in heart
failure). Offer warm, rather
than cold, fluids.
COLLABORATIVE:
1.Assist with/monitor effects
of nebulizer treatments and
other respiratory
physiotherapy (e.g., postural
drainage)
2.Administer medications as
indicated.
3.Provide supplemental
fluids; e.g., IV, humidified
oxygen, and room
humidification.
4.Monitor ABGs, pulse
oximetry reading.
Fluids (especially warm liquids) aid in mobilization and
expectoration of secretions.
COLLABORATIVE:
Facilitates liquefaction and removal of secretions.
Postural drainage may not be effective in interstitial
pneumonias or those causing alveolar
exudate/destruction.
Aids in reduction of bronchospasm and mobilization of
secretions. Analgesics are given t improve cough effort
by reducing discomfort, but should be used cautiously
because they can decrease cough effort/depress
respirations.
Fluids are required to replace losses (including
insensible) and aid in mobilization of secretions. Note:
some studies indicate that room humidification has been
found to provide minimal benefit and is thought to
increase the risk of transmitting infection.
Follow progress and effects of disease process/therapeutic
regimen and facilitates necessary alterations in therapy.
NURSING DIAGNOSIS: Ineffective Airway Clearance related to the presence of thick secretions.
Assessment Planning Interventions Rationale Evaluation

3. Objected Data:
Labored
breathing

VS Taken:
RR-29 cpm
(labored
breathing)
02SAT- 86%
BP- 60/40 mmHg
T- 35.4
PR- 135 bpm
At the end of 8-hour
student nurse-client
interactions, patient will be
able to:
Maintain a patent
airway with
minimal secretions;
Patient’s oxygen
saturation will
improve and
remain above 92%
during and after
Ambu bag use.
INDEPENDENT:
1.Assess the color, consistency,
and amount of secretions.
2.Auscultate lung sounds to
check for the presence of
crackles or wheezes.
3.Encourage coughing if the
patient is alert and able to
participate.
4.Elevate head of bed, change
position frequently.
5.Ensure proper positioning
(semi-Fowler’s or high-
Fowler’s if possible).
6.If not contraindicated,
encourage hydration through
IV fluids or oral fluids as
tolerated.
7.Educate family on airway
clearance techniques and the
purpose of humidified oxygen
and suctioning.
DEPENDENT:
8.Attach humidification to the
oxygen source when using the
Ambu bag.
9.Perform oropharyngeal or
nasopharyngeal suctioning as
needed to clear excess
INDEPENDENT:
1.Helps determine if secretions are thick,
which may require additional interventions
(e.g., suctioning, humidification).
2.Identifies areas of congestion that may affect
ventilation and oxygenation.
3.Coughing helps mobilize secretions and can
prevent them from obstructing the airway.
4.Keeping the head elevated lowers diaphragm,
promoting chest expansion, aeration of lung
segments, and mobilization and
expectoration of secretions to keep the
airway clear
5.Facilitates lung expansion and helps in
mobilizing secretions.
6.Adequate hydration helps thin secretions,
making them easier to clear.
7.Helps to alleviate anxiety and provides
family members with an understanding of
interventions.
DEPENDENT:
8.Humidified oxygen can help thin secretions,
making them easier to clear.
9.Helps maintain a clear airway and facilitates
effective ventilation.
10.Ensures effective ventilation while
preventing hyperventilation or gastric
insufflation.
At the end of 8-hour
student nurse-client
interactions, patient was
able to:
Maintain a patent
airway with
minimal secretions.
Patient’s oxygen
saturation will
improve and
remain above 92%
during and after
Ambu bag use.

4. secretions.
10.Deliver ventilations with the
Ambu bag at an appropriate
rate (12-20 breaths per minute
in adults) and observe for
adequate chest rise.
NURSING DIAGNOSIS: Deficit fluid volume related to vomiting and potential dehydration.
Assessment Planning Interventions Rationale Evaluation

5. Objective Data:
Low Sodium and
Low Potassium
Vomiting
The patient will maintain
adequate hydration levels
as evidenced by balanced
intake and output, stable
vital signs, and improved
skin turgor within 8 hours.
INDEPENDENT:
1.Monitor vital signs every
4 hours, focusing on
blood pressure, heart
rate, and temperature.
2.Encourage the patient to
drink small sips of water
or an oral rehydration
solution every 30
minutes, as tolerated.
3.Administer IV fluids as
prescribed (e.g., isotonic
saline) and assess for any
signs of fluid overload.
4.Administer antiemetics
as prescribed and
document their
effectiveness.
5.Educate the patient and
family on the importance
of maintaining adequate
hydration, signs of
dehydration, and steps to
take if vomiting
continues.
INDEPENDENT:
1.Vital signs provide an
indication of the body’s fluid
status. For example, a
decrease in blood pressure
with an increase in heart rate
can indicate fluid volume
deficit due to vomiting.
2.Rationale: Small amounts at
frequent intervals can prevent
further vomiting and help to
gradually replace lost fluids.
3.Intravenous fluids help
replace fluids rapidly and are
essential when the patient
cannot retain oral fluids due
to vomiting.
4.Antiemetics help control
vomiting, which can decrease
fluid loss and improve the
patient’s comfort.
5.Education helps patients and
families recognize early
symptoms of dehydration and
understand how to manage it,
which is crucial for
prevention.

6. NURSING DIAGNOSIS: Acute Pain related to inflammation and irritation of the stomach lining.
Assessment Planning Interventions Rationale Evaluation
NURSING DIAGNOSIS: Deficient Knowledge regarding gastritis management, dietary modifications, and prevention of complications.

7. Assessment Planning Interventions Rationale Evaluation
NURSING DIAGNOSIS: Imbalanced Nutrition: Less than Body Requirements related to decreased appetite and altered digestion.
Assessment Planning Interventions Rationale Evaluation

8. NURSING DIAGNOSIS: Acute Pain related to inflammation and irritation of the stomach lining.
Assessment Planning Interventions Rationale Evaluation

9. NURSING DIAGNOSIS: Deficient Knowledge regarding gastritis management, dietary modifications, and prevention of complications.
Assessment Planning Interventions Rationale Evaluation

10. NURSING DIAGNOSIS:
Assessment Planning Interventions Rationale Evaluation

11. NURSING DIAGNOSIS:
Assessment Planning Interventions Rationale Evaluation