Esophagitis Assessment Subjective: Hindi ako gaanong makakain at parang wala akong gana as claimed.

Objective: Pale Conjunctivitis and mucous membrane Poor muscle tone and loss of weight with Adequate food intake Nursing Diagnosis Altered nutrition: less than body requirements related to inability to ingest and digest food as manifested by sudden loss of weight Planning To establish a nutritional plan that meets the patient needs within 2 weeks Intervention To provide diet modification; advise patient to increase protein and carbohydrates To advise patient to avoid food that cause intolerances and increase gastric motility To instruct patient to eat small, frequent feedings and in high fowlers potion during and 1 hour after meal To take the prescribed medications such as antacids Rationale To meet patients nutritional needs Evaluation Goal met. The nutritional plan was well establish; the patients nutritional problem was corrected, patients weight increased

To prevent aggravation of patients condition

To be able to tolerate the food ingested

To promote patients condition and wellness

Esophagitis Assessment Subjective: Medyo masakit ang paglunok ko tuwing kumakain. Nursing Diagnosis Acute pain related to inflammed lining of esophagus as evident of difficulty of swallowing Planning To assist patient explore methods of alleviating or controlling pain during the shift Intervention To encourage verbalization of feeling To provide comfort measures in preventing pain To instruct patient to eat in high fowlers position To avoid alcohol, spices and other irritants To administer analgesics as ordered To control pain felt by the patient Rationale To assess the degree of pain Evaluation Goal met. The pain felt by the patient was lessen

Objective: Difficulty of swallowing Unable to eat because of pain

To provide non pharmacologic pain management

Crohns Disease Assessment Subjective: Nahihiya ako lumabas at makipag usap s mga kaibigan ko palagi kasing humihilab ung tiyan ko, minuminuto akong nasa banyo as claimed. Objective: Avoidant behavior Decrease use of social support Change in visual communication pattern Inability to meet basic needs Nursing Diagnosis Ineffective coping related to repeated episodes of diarrhea Planning After 8 hours of nursing intervention the patient will be able to meet physiological needs as evidenced by appropriate expression of feelings Intervention To determine previous methods of dealing with life problems To call patient by name. ascertain how patient prefers to be addressed Explain disease process/procedures/ events in a simple concise manner Comfort patient when behavior is inappropriate. Pointing out difficulty in words and action Rationale To indentify successful techniques that can be used in current situation Using the patients name enhances sense of self and promotes self esteem May help patients to express emotions, grasp situation and feel more in control Provides external focus control, enhancing safety Evaluation After 8 hours of nursing intervention the patient will be able to meet physiological needs as evidenced by a appropriate expression of feelings

Crohns Disease Assessment Subjective: Pabalik balik ako s banyo para dumumi at sumuka ako pero wala naman maisuka as claimed. Objective: Decreased urine output Decreased pulse pressure Poor skin turgor Dry skin/mucous membrane VS BP = 100/80 T = 36.2 PR = 99 RR =24 Nursing Diagnosis Deficient fluid volume anorexia, nausea and diarrhea Planning After 8 hours of nursing intervention the patient will maintain his fluid volume at a functional level that will be evidenced by adequate urinary output stable vital signs and moist mucous membrane Intervention Monitor intake and output of the patient Rationale To detect fluid deficit and evaluate the effectively of fluid replacement therapy To replace the losses of fluid more effectively through practicing the patients right to autonomy Evaluation After 8 hours of nursing intervention the patient was able to maintain his fluid volume at a functional level evidenced by adequate urinary output, stable vital signs and moist mucous membrane

Note the patients preference regarding fluids and food with high fluids content. Keep fluids within patients oral reach and encourage frequent intake as appropriate Provide frequent oral care as well as eye care Encourage perianal care

To prevent injury from dryness

To prevent growth of bacteria and the occurrence of infection

Diverticulosis Assessment Subjective: Tatlong araw n po akong ndi madumi as claimed. Objective: Dry, hard, formed stool Straining with defecation Dark or bloody or tarry stool Nursing Diagnosis Constipation related to presence of inflammation as evidenced by decreased in frequency of stool Planning Intervention Rationale To improve consistency of stool and facilitate passage in the colon Evaluation Goal met. The patient was able to have a acceptable pattern of elimination

To facilitate patients To encourage acceptable pattern of balanced fiber and elimination within the bulk diet day

To advise adequate fluid intake, including high fiber, fruit juices and drink warm stimulating fluids To encourage exercise within limits of individual activity To administer stool softener, mild stimulants or bulk forming agents

To promote softening of stool

To stimulate contractions of the intestines To facilitate passage of feces

Diverticulosis Assessment Subjective: Sumasakit ang aking tiyan kapag kumakain as claimed. Objective: Diaporesis Vital signs increased RR = 30 PR = 120 Nursing Diagnosis Acute pain related to inflammation of mucosal lining of intestine as evident by verbal aspects of pain Planning To control pain felt by the patient within 8 hours period Intervention To administer enemas To advice weight reduction Rationale To remove impacted stool To reduce intraabdominal pressure To soften stool Evaluation Goal met. The pain experienced by the patient was eliminated

To encourage fluid intake To encourage patient to avoid smoking and alcohol and corrosive substances To administer prescribed medication such as analgesics and antibiotics

To prevent aggravation of condition

To control the pain and to hinder aggravation of condition

WESLEYAN UNIVERSITY PHILIPPINES MABINI EXT. CABANTUAN CITY COLLEGE OF NURSING

SUBMITTED BY: RENATO C. BALARIA BSN IV blk 4

SUBMITTED TO: PROF. BENJAMINE BREBONERIA, RN, MAN