Sample of Assessment - Nursing Care Plan Gastritis

Sample of Nursing Care Plan for Gastritis

Nursing Assessment

1. Anamnese include:
   • Name :
     
   • Age :
     
   • Gender :
     
   • Type of work :
     
   • Address :
     
   • Tribe / Nation :
     
   • Religion :
     
   • The level of education: for those with low education level / low gain knowledge of gastritis, it will underestimate the disease, even just think of gastritis as upset stomach and will eat regular foods that can cause and exacerbate the disease.
   • History of illness and health
     • The main complaint: Pain in the pit of the stomach and lower right abdomen.
     • History of the disease at this time: Covers the journey of illness, initial symptoms are felt from the client, complaints arise suddenly or gradually felt, trigger factors, efforts to resolve the issue.
     • Past history of disease: Includes diseases associated with the disease now, history of the hospital, and a history of drug use.
   
   
   
2. Physical examination, the Review of systems (ROS)
   
   General condition: there was pain on physical examination there is tenderness in the epigastric quadrants.
   
   • B1 (breath): tachypnea
   • B2 (blood): tachycardia, hypotension, dysrhythmias, weak peripheral pulses, peripheral charging slow, pale skin color.
   • B3 (brain): headache, weakness, level of consciousness can be disturbed, disorientation, pain epigastrum.
   • B4 (bladder): oliguria, fluid balance disorders.
   • B5 (bowel): anemia, anorexia, nausea, vomiting, heartburn, intolerance to spicy foods.
   • B6 (bone): fatigue, weakness



3. Assessment Focus
   1. Activity / Rest
      Symptoms: weakness, fatigue
      Signs: tachycardia, tachypnea / hyperventilation (in response to activity)
   
   
   2. Circulation
      Symptoms: weakness, sweating
      Signs:
      
      • Hypotension (including postural)
      • Tachycardia, dysrhythmias (hypovolemia / hypoxemia)
      • Weak peripheral pulse
      • Slow capillary refill (vasoconstriction)
      • Skin color pale, sianosis (depending on the number of blood loss)
      • Weakness of skin / mucous membranes, sweating (shows status of shock, acute pain, psychological responses)
      
      
   3. Ego integrity
      Symptoms: acute or chronic stress factors (financial, labor relations), feelings of helplessness.
      Sign: a sign of anxiety, such as anxiety, pallor, sweating, narrowing of attention, shaking, trembling voice.
   
   
   4. Elimination
      Symptoms: a history of previous hospitalization due to bleeding gastroenteritis (GE) or problems associated with GE, such as injury or gastric ulcer, gastritis, gastric surgery, gastric irradiation area. Changes in bowel habit / characteristic stool.
      Signs:
      
      • Abdominal tenderness, distention
      • Bowel sounds: often hyperactive during hemorrhage, hypo-active after the bleeding.
      • The characteristics feses: diarrhea, blood color of dark, brownish or sometimes red bright, foamed, odor rotten (steatorrhoea), constipation can occur (a change diet, the use of antacids).
      • Urinary output: decreased, concentrated.
      
      
   5. Food / fluid
      Symptoms:
      
      • Anorexia, nausea, vomiting (throwing up that extends beyond the pyloric obstruction suspected in connection with a duodenal injury),
      • Swallowing problems: hiccups
      • Heartburn, sour belching, nausea or vomiting
      Symptoms: vomiting with a dark coffee color or bright red, with or without blood clots, dry mucous membranes, decreased mucus production, poor skin turgor (chronic bleeding).
   
   
   6. Neurosensory
      Symptoms: flavor pulsed, dizziness / sick heads because of rays, weakness.
      Sign: the level of consciousness can be impaired, the range of slightly inclined to sleep, disorientation / confusion, fainting and coma (depending on the volume of circulation / oxygenation).
   
   
   7. Pain / Comfort
      Symptoms:
      
      • Pain, described as a sharp, shallow, burning, stinging, sudden severe pain may be accompanied by perforation. Sense of discomfort / distress faint after eating a lot and lost with a meal (acute gastritis).
      • Pain epigastrum left until the middle / back or spread to occur 1-2 hours after eating and relieved by antacids (gastric ulcers).
      • Pain left to epigastrum / or spread to his back occurred approximately 4 hours after eating when the stomach is empty and relieved by food or antacids (duodenal ulcer).
      • No pain (esofegeal varices or gastritis).
      • Trigger factors: food, cigarettes, alcohol, the use of certain drugs (salicylates, reserpine, antibiotics, ibuprofen), psychological stressors.
      Signs: wrinkled face, be careful in the area of ​​pain, pallor, sweating, narrowing attention.
   
   
   8. Security
      Symptoms: allergy to the drug / sensitive
      Sign: an increase in temperature, spider angioma, palmar erythema (showing cirrhosis / portal hypertension)
   
   
   9. Guidance / Learning
      Symptoms: the use of prescription drugs