Nursing Care Plan Problem No 1: Epigastric Pain

Nursing Diagnosis Cues Nursing Diagnosis: Acute Pain related to chemical burn of gastric mucosa secondary to excessive gastric acid secretion. Cues: Subjective: Sakit kaayo akong kutokuto og naghilab pag ayo. Labi na kada human ug kaon,as verbalized by the patient. -Pain Scale of 6 out of 10 Objective: -Facial grimace -Abdominal Guarding -Restlessness -Diaphoresis -Vital Signs taken as follows: T- 36.5C P- 70 bpm R- 24 cpm BP- 130/90mmHg

Objectives After 30 minutes 1 hour of nursing intervention, the patient will be able to: - Identify current level of pain.

Nursing interventions

Evaluation After 30 minutes- 1 hour of nursing intervention, the objective was :

Independent Interventions:
-Assess and note reports of pain, including location and duration.

-met. The patient was able to report current level of pain which is 6 out of 10 using pain scale and was able to identify its location which is in the epigastric area and duration of pain which is almost 30 minutes after 2 hours from ingestion of food.

-Demonstrate a relaxed body posture and be able to sleep/rest appropriately.

-Encourage patient to assume position of comfort.

-partially met. The patient was able to maintain in relaxed supine position but was not able to get enough rest/sleep due to discomfort. -met. The patient was able to perform non-pharmacological ways on how to control pain such as controlled breathing, reading and listening to music. In addition he was able to enumerate foods that should be avoided to reduce occurrence of pain.

-Describe a non pharmacological method that can be used to control pain.

-Help client use non pharmacological methods such as distraction (e.g., music, television, reading, stroking, controlled breathing, massage and heat applications as ordered and as therapeutic to client). -Identify and limit foods that create discomfort such as spicy or carbonated drink.

Nursing Diagnosis Cues

Objectives

Nursing interventions -Advise patient to avoid extremely hot or cold food, solid foods and instruct to chew thoroughly and to eat in a leisurely fashion. -Encourage small frequent meals.

Evaluation

Problem No 2 : Body weakness

Nursing Diagnosis Cues Nursing Diagnosis: Fatigue related to decrease oxygen supply to tissues secondary to anemia. Cues: Subjective Cue: Kapoy kayo og luya akong lawas unya kung malibang ko itom ang akong tae, as verbalized by the patient. Objective Cues: -lethargy or listlessness -decrease energy in performing ADLs. Objectives After 8 hours of nursing interventions, the patient will be able to: -Identify basis of fatigue and individual areas of control. Nursing interventions
Independent interventions: -Assess severity of fatigue on a scale of 010; assess frequency of fatigue, activities associated with increased fatigue and basis of fatigue. -Evaluate adequacy of nutrition and sleep. -Encourage client to express feelings about fatigue; use of active listening techniques; help identify sources of hope. -Accept reality of client reports of fatigue and do not underestimate effect on quality of life the client experiences. -Plan care and schedule activities for

Evaluation After 8 hours of nursing interventions, the objective was : -met. The patient identified basis of fatigue such as from present condition, less adequate nutrition and decrease amount of sleep because of epigastric pain.

-preference of always lying in bed -hematocrit level as of 5 Sept-.21

periods when client has the most energy.

-Perform ADLs( performing personal hygiene/ self care) and participate in desired activities (walking and stretching) at level of ability. -Participate in recommended treatment program.

-partially met. The patient agreed and performed activities that he can only do within his tolerance such as self care and walking within the vicinity of the hospital with assistance from SO but refuse to do simple -Provide environment conducive to relief of stretching.
fatigue.

-partially met. The patient participated in activities recommended to reduce fatigue and at the same time consented to have a blood transfusion to increase the blood volume but -Teach stress reduction techniques such within the shift, still complaint of fatigue. He as controlled breathing. also took the medications prescribed by the doctor to improve his condition.
-Provide diversional overstimulation. activities. Avoid

Nursing Diagnosis/ Cues

Objectives

Nursing interventions Dependent Interventions: -Provide blood transfusion as prescribed by the physician.
-Administer

Evaluation

prescribed medications:
-Tranexamic Acid 500mg 1 cap every 8 hours -Moriamin Forte 1 cap P.O every 8 hours

Problem No 3: Weight Loss Nursing Diagnosis Cues Nursing Diagnosis: Altered Nutrition less than body requirements related to inability to digest food and absorb nutrients secondary to gastric outlet obstruction (duodenum). Cues: Subjective Cue: Wala koy gana mukaon ug sige pa gyud kog suka kada human ug kaon , as verbalized by the patient. Objectives After 8 hours of nursing interventions, the client will be able: -Verbalizes an understanding of nutritional requirements. Independent Interventions: Nursing interventions Evaluation After 8 hours of nursing interventions, the objective was: -met. The patient was able to verbalize I-Assess dietary habits, recent food an understanding of the nutritional intake. Note degree of difficulty with requirements he needs in order to gain eating. Evaluate weight and body mass. and improve his body weight which is 38 k. -Explain the need for consumption of carbohydrates, protein, minerals, fats and liquid. - Discuss eating habits, including food preferences, intolerances/ aversions.

Objective Cues: -Loss of body weight -vomiting -Demonstrate behaviors after patient eats plenty to eat adequate amount of food of food. -Lack of interest in food -Pale conjunctival and mucous membrane -Endoscopy findings: 1.Gastric outlet obstruction 2.Reflux Esophagitis Present body weight: 38 kg Nursing Diagnoses Cues Objectives

-Encouraged to do frequent oral care as appropriate. -partially met. The patient still eats food that are hard to digest like rice and meat - Encourage a rest period of 1 hour even if the prescribed diet is soft. before and after meals. Provide frequent small feedings. -Instruct patient to avoid very hot, very cold foods and foods that are hard to diges

Nursing interventions -Encourage to consume soft and liquid foods. -Limit foods that create discomfort such as spicy or carbonated drink. -Promote pleasant, relaxing environment, including socialization when possible. - Promote adequate/timely fluid intake. -Weigh client twice a week.

Evaluation

-State factors that -Encourage the patient to perform ADLs contribute to weight gain. ( performing personal hygiene) and

-met. The patient showed appreciation on the factors that contribute weight gain

simple exercise (walking) within tolerance with rest periods in between. -Offer fluids shortly before meals. Dependent Intervention: -Administer prescribed medication helpful for weight gain:
-Moriamin Forte 1 cap P.O every 8 hours

and perform ADLs (performing personal hygiene) and simple exercise ( walking) . In addition, patient took the prescribed medication and understood its indication.