S:
“Nurse umuubo and sumusuka ako ng dugo, sumasakit pati ung tiyan ko.” As verbalized by the patient.
O:
>(+) hematemesis
> coughing
>DOB
>pale in appearance.
DIAGNOSIS
Risk for aspiration related to vomiting secondary to ulcer.
PLANNING
After 8 hrs of nursing intervention the client will be able reduce risk for aspiration
INTERVENTION
>assess for airway, breathing and circulation of the client
>Elevate head of bed (HOB) at least 30* at all times.
>position patient in left lateral decubitus.
> make sure oral-tracheal suction machine at the bed side.
>Administer IVF as prescribed
>Administer meds as prescribe.
>Provide emotional support to client, explain all procedures.
> Provide prescribed diet.
>Prepare client and his family for surgical intervention if required for recurrent ulcer, hemorrhage, or perforation.
RATIONALE
>Protection of the airway with intubation may be needed to avoid respiratory compromise from aspiration of blood
>Elevating the HOB can improve airway and reduce risk for aspiration.
>left lateral decubitus position will help prevent aspiration of GI contents
>to provide initial intervention when the client experienced aspiration.
>To replace amount of blood loss.(Replace according to the amount of blood lost)
>antacids, antiemetics etc. can help reduced GI bleeding
>To decrease anxiety and to obtain client’s cooperation.
> avoid irritating foods, coffee, milk, bland diet.
> When therapy does not produce healing, surgery is required.
EVALUATION
After 8hours of nursing intervention the goal was met, the client was able to reduce risk for aspiration.
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