NURSING CARE PLAN FOR HIATAL HERNIA

ASSESSMENT NURSING INFERENCE PLAN OF INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS CARE
Subjective Data: Risk for Dyspnea and Short Term 1. Monitor respiratory rate, depth, 1. Signs of aspiration should be Short Term Goal:
The patient aspiration coughing are Goal: and effort. Note any signs of detected as soon as possible Within an hour of
complained of related to caused by aspiration such as dyspnea, to prevent further aspiration nursing
frequent recurrent gastric acids Within an cough, cyanosis, wheezing, or and to initiate immediate interventions,
regurgitation after regurgitation that have hour of fever. treatment. the client was able
meals and of gastric entered the nursing 2. Auscultate for lung sounds 2. To determine presence of to demonstrate
vomiting of blood. contents lungs. The interventions, 3. Assess patient’s ability to secretions in the lungs. relief from dyspnea
“Maasim ang regurgitation of the client will swallow and the presence 3. Loss of the gag reflex and coughing. The
panlasa ko at gastric acids demonstrate of gag reflex.  increases the risk of client was able to
mahapdi sa cause swelling relief from 4. Avoid placing patient aspiration. experience less
lalamunan ang of the airways dyspnea and in supine position, have the 4. Supine position after meals and clear
pakiramdam. and stimulates coughing. The patient sit upright after meals. can increase regurgitation of regurgitation of
Nauubo ako dahil coughing client will also 5. Elevate HOB while in bed.. acid. gastric acids.
may mahapdi sa reflex. experience 6. Instruct the patient to chew 5. To prevent aspiration by
lalamunan ko. May less and clear food thoroughly and eat slowly. preventing the gastric acid to
konting dugo din regurgitation 7. Assist/instruct in relaxation flow back in the esophagus.
po sa suka ko.” of gastric techniques, e.g., deep/slow 6. Well-masticated food is easier
acids. breathing to swallow. Food should be Long Term Goal:
cut into small pieces.
Objective Data: Long Term DEPENDENT/ COLLABORATIVE: 7. Helpful in decreasing The client was
T: 36.5 C Goal: discomfort and difficulty in able to reduce the
PR: 83 bpm 8. Administer Antacids as breathing. risk of aspiration
RR: 10 cpm The client will ordered. as evidenced by
BP:120/80 mmHg be able to 9. Instruct patient to avoid highly DEPENDENT/ COLLABORATIVE: effective breathing
O2 Sat.: 95% reduce the seasoned food, acidic juices, 8. To minimize gastric and no coughing
risk of alcoholic drinks, bedtime hyperacidity and minimize within 2 days of
Patient is aspiration as snacks, and foods high in fat. episodes of regurgitations. nursing
observed with evidenced by 9. These can reduce the lower interventions. The
discomfort, effective esophageal sphincter client also
dyspnea and breathing and pressure and decrease the experienced no
coughing. no coughing production of gastric acids. regurgitation of
within 2 days gastric acids.
of nursing
interventions.
The client will
also
experience no
regurgitation
of gastric
acids
 ASSESSMENT NURSING INFERENCE PLAN OF INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS CARE
Subjective Data: Acute pain Short Term 1. Assess for heartburn. 1. To determine the presence of Short Term Goal:
The patient related to Goal: (characteristic, severity, GERD. Heartburn is the most
complained of irritation in frequency) common feature of GERD.  Within an hour of
regurgitation of the Within an 2. Carefully assess pain location 2. Pain of esophageal spasm nursing
acid and esophageal hour of and discern pain from GERD resulting from reflux interventions,
heartburn. mucosa as nursing and angina pectoris. esophagitis tends to be the client was able
evidenced by interventions, 3. Avoid placing patient chronic and may mimic angina to report relief from
“Maasim ang regurgitation the client will in supine position, have the pectoris: radiating to the neck, pain as evidenced
panlasa ko at of acid and report relief patient sit upright after meals. jaws, and arms. by a decrease in
mahapdi sa heart burn. from pain as 4. Elevate HOB while in bed.. 3. Supine position after meals the rating of chest
lalamunan ang evidenced by 5. Instruct the patient to chew can increase regurgitation of pain by 7/10 to
pakiramdam. a decrease in food thoroughly and eat slowly. acid. 5/10.
Nauubo ako dahil the rating of 6. Assist/instruct in relaxation 4. To prevent aspiration by
may mahapdi sa chest pain by techniques, e.g., deep/slow preventing the gastric acid to Long Term Goal:
lalamunan ko. 7/10 to 5/10. breathing flow back in the esophagus.
Mainit at masakit 5. Well-masticated food is easier The client was
ang pakiramdam Long Term to swallow. Food should be able to feel
sa dibdib ko. Goal: DEPENDENT/ COLLABORATIVE: cut into small pieces. relieved from pain
Nararamdaman ko 7. Administer Antacids as 6. Helpful in decreasing and did not
din ang sakit sa The client will ordered. discomfort and difficulty in experience
may braso ko.” be relieved 8. Instruct patient to avoid highly breathing. heartburn and
from pain and seasoned food, acidic juices, regurgitation within
will not alcoholic drinks, bedtime 2 days of nursing
Objective Data: experience snacks, and foods high in fat DEPENDENT/ COLLABORATIVE: interventions.
T: 36.5 C heartburn and . 7. To minimize gastric
PR: 83 bpm regurgitation hyperacidity and minimize
RR: 10 cpm within 2 days episodes of regurgitations and
BP:120/80 mmHg of nursing heartburn
O2 Sat.: 95% interventions. 8. These can reduce the lower
esophageal sphincter
Patient is pressure and decrease the
observed with production of gastric acids.
discomfort and
guarding behavior
in the chest.

Pain Scale of 7/10.

 ASSESSMENT NURSING INFERENCE PLAN OF INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS CARE
Subjective Data: Knowledge Limited health Short Term 1. Assess patient for information 1. Provides a basis for patient Short Term Goal:
“Hindi ko alam deficit related literacy skills Goal: needed and ability to perform teaching.
kung bakit laging to lack of are often actions independently. 2. Provides knowledge and Client did not
samasakit ang information greater among Client will 2. Provide patient with information facilitates compliance. experience heart
sikmura at dibdib regarding certain groups; have an regarding disease 3. Gravity helps control reflux burn and
ko pagkatapos condition/dis older adults, increased process, health practices that and causes less irritation from regurgitation after
kumain.” as ease process people with knowledge can be changed, and reflux action into the 2 hours of nursing
verbalized by the as evidenced limited regarding medications to be utilized. esophagus. interventions.
patient. by presence education, actions 3. Instruct patient regarding eating 4. Promotes comfort by
of minority preventing the small amounts of bland food the decrease in intra- Long Term Goal:
preventable population. occurrence of followed by a small amount of abdominal pressure, which
complication Clients with low heart burn water. Instruct to remain in reduces the reflux of gastric The client showed
s. literacy skills and upright position at least 1–2 contents. full understanding
have less regurgitation hours after meals, and to avoid 5. Helps prevent reflux. and implemented
information after 2 hours eating within 2–4 hours of 6. These food items increase ways to prevent
about health of nursing bedtime. acid production that the occurrence of
promotion interventions. 4. Instruct patient to avoid precipitates heartburn and heart burn and
and/or bending over, coughing, increased reflux. regurgitation after
management Long Term straining at defecations, and 7. Promotes knowledge, 2 hours of nursing
of a disease Goal: other activities that increase facilitates compliance with interventions.
process for reflux. treatment, and allows for
themselves. The client will 5. Instruct patients to eat slowly, prompt identification of
be able to chew foods well and maintain a potential need for changes in
fully high-protein, low-fat diet. medication regimen to prevent
understand 6. Instruct patient to avoid complications.
and temperature extremes of food,
implement the spicy foods, and citrus, and gas
ways to forming foods.
prevent the 7. Instruct patient in medications,
occurrence of effects, side effects, and to
heart burn report to physician if symptoms
and persist
regurgitation despite medication treatment.
after 2 hours
of nursing
interventions.
NURSING CARE PLAN FOR GI BLEEDING

ASSESSMENT NURSING INFERENCE PLAN OF INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS CARE
Subjective Data: Fluid Volume Short Term 1. Assess vital signs particularly 1. Hypovolemia due to GI bleeding Short Term Goal:
The patient Deficit Goal: blood pressure level. may lower blood pressure levels Within an 3 hours
complained related to 2. Note characteristics of vomitus or and put the patient at risk for of nursing
dizziness and blood volume Within an 3 drainage. hypotensive episodes that lead to interventions,
vomiting of blood. loss hours of 3. Monitor patient’s intake and shock. Changes in blood pressure the client was able
“Nanghihina po secondary to nursing output. may also be used to estimate blood to have a blood
ako at GI bleeding interventions, 4. Assess/ weigh the patient daily. loss. pressure level of
nahihilo.Masakit as evidenced the client will 5. Monitor active fluid loss from 2. Helpful in determining cause of 120/80 mmHg and
din po yung tiyan by have a blood bleeding, and vomiting; maintain gastric distress. showed no signs
ko tatlong araw hematemesis pressure level accurate input and output record. 3. To monitor patient’s fluid volume of body weakness.
na.mahapdi na and of 120/80 6. Monitor for the existence of factors accurately.
mainit po yung hypotension. mmHg and no causing deficient fluid volume (e.g., 4. Weight is the best assessment
pakiramdam. body gastrointestinal losses/ bleeding) data for possible fluid volume
Tatlong araw na weakness. 7. Urge the patient to drink imbalance.
din po ako prescribed amount of fluid. 5. Fluid loss from bleeding, and Long Term Goal:
nagsusuka at may Long Term vomiting cause decreased fluid
dugo din po sa Goal: volume and can lead to The client was
suka ko.” dehydration. able to manifest
The patient DEPENDENT/ COLLABORATIVE: 6. Early detection of risk factors and absence of GI
will manifest early intervention can decrease the bleeding as
Objective Data: absence of GI Administer IV therapy as prescribed. occurrence and severity of evidenced by no
T: 37 C bleeding as complications from deficient fluid blood in the vomit,
PR: 83 bpm evidenced by Administer blood transfusion as volume.  a hemoglobin (HB)
RR: 10 cpm no blood in prescribed. 7. To replenish fluids and level of over 13
BP:90/60 mmHg the vomit, a electrolytes lost from vomiting or g/dl, blood
O2 Sat.: 95% hemoglobin Identify an emergency plan, other gastric losses, and to promote pressure level
(HB) level of including when to ask for help. better blood circulation around the within the normal
Lab work shows over 13 g/dl, body. range, no body
Hemoglobin level blood weakness and
@ 7.4 g/dl pressure level DEPENDENT/ COLLABORATIVE: normal skin color.
within the To replenish fluids and electrolytes
Patient is normal range, lost from vomiting or other gastric
observed with no body losses, and to promote better blood
pallor and weakness and circulation around the body.
discomfort. normal skin
color. To increase the hemoglobin level
and treat anemia and hypovolemia
related to GI bleeding.

Some complications of deficient

fluid volume cannot be reversed in
the home and are life-threatening.
Patients progressing toward
hypovolemic shock will need
emergency care.

Normal hemoglobin level For men, 13.5 to 17.5 grams per deciliter. For women, 12.0 to 15.5 grams per deciliter.
 ASSESSMENT NURSING INFERENCE PLAN OF INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS CARE
Subjective Data: Risk for In portal Short Term 1. Determine the patient’s health 1. Early identification of possible risks Short Term Goal:
The patient bleeding hypertension, Goal: history for signs that can be associated for bleeding provides a foundation for Within 2 hours of
complained related to collateral Within 2 hours with a risk for bleeding such as liver implementing appropriate preventive nursing
dizziness, presence of circulation of nursing disease, inflammatory bowel disease, measures. interventions,
weakness and esophageal develops in the interventions, or peptic ulcer disease. 2. Hypotension and tachycardia are the client was able
presence of blood varices. lower the client will 2. Monitor patient’s vital signs, initial compensatory mechanisms to report no
in vomitus. esophagus as not especially BP and HR. usually noted with bleeding. experience in
. venous blood, experience 3. Evaluate the patient’s use of any 3. Drugs that interfere with clotting bleeding as
“Nanghihina po which is bleeding as evidenced by a
medications that can affect hemostasis mechanisms or platelet activity
ako at nahihilo. diverted from evidenced by blood pressure
(e.g, anticoagulants, salicylates, NSAIDs, increase risk for bleeding.
Nagsusuka po ako the GI tract and a blood within the normal
or cancer chemotherapy). 4. These laboratory tests provide
at may konting spleen pressure range, no
4. Review laboratory results for important information about the
dugo po na because of within the presence of blood
kasama sa suka portal normal range, coagulation status as appropriate: patient’s coagulation status and in the vomitus,
ko.” obstruction, no presence platelet count. bleeding potential. stable hematocrit
seeks an of blood in the 5. Monitor hematocrit (Hct) and 5. When bleeding is not visible, and hemoglobin
outline. vomitus, hemoglobin (Hgb). decreased Hgb and Hct levels may be levels.
Because of stable an early indicator of bleeding.
Objective Data: excessive hematocrit and
T: 37 C intraluminal hemoglobin Long Term Goal:
PR: 83 bpm pressure, these levels. DEPENDENT/ COLLABORATIVE: The client reported
RR: 10 cpm collateral veins Educate the at-risk patient about DEPENDENT/ COLLABORATIVE: no bleeding and
BP:90/60 mmHg become Long Term precautionary measures to prevent Information about precautionary have a blood
O2 Sat.: 95% tortuous, Goal: tissue trauma or disruption of the measures lessens the risk for pressure within the
dilated, and The client is normal clotting mechanisms. bleeding. normal range and
Lab work shows fragile. They expected to no presence of
Hemoglobin level are prone to have no When laboratory values are abnormal, Blood product transfusions replace blood in the
@ 7.4 g/dl ulceration and bleeding and administer blood products as blood clotting factors; RBCs increase vomitus.
hemorrhage. have a blood prescribed. oxygen-carrying capacity; FFP replaces The client was
EGDfindings: Rupture of pressure clotting factors and inhibitors; able to fully
presence of esophageal within the Educate the patient and family understand and
platelets and cryoprecipitate provide
esophageal varices is the normal range implement
members about signs of bleeding that proteins for coagulations.
varices. most common and no measures to
need to be reported to a health care
cause of death presence of prevent and
provider. Early evaluation and treatment of
of clients with blood in the recognize signs of
hepatic bleeding by a health care provider
vomitus. bleeding
cirrhosis. Inform the patient to check the color reduce the risk for complications from
The client will interventions.
and consistency of stools. blood loss.
be able to
fully
Educate the patient about over-the- Bright red blood in the stools is an
understand
and counter drugs and avoid products that indicator of lower gastrointestinal
implement contain aspirin or NSAIDs such as bleeding. Stool that has a dark
measures to ibuprofen and naproxen. greenish-black color and a tarry
prevent and consistency is linked with upper
recognize gastrointestinal bleeding.
signs of
bleeding hese drugs not only decrease normal
interventions.
 platelet aggregation but also decrease
the integrity of gastric mucosa
through inhibition of cyclooxygenase
(COX)-1 inhibitor and therefore
increase the risk for gastrointestinal
bleeding.

Drugs that interfere with clotting mechanisms or platelet activity increase risk for bleeding. Salicylates and other NSAIDs inhibit cyclooxygenase 1 (COX)-1, an enzyme that promotes platelet
aggregation. Warfarin, an oral anticoagulant, inhibits the synthesis of vitamin K in the liver, thus reducing levels of several subsequent clotting factors. Heparin, a parenteral anticoagulant,
inhibits the action of thrombin and prevents formation of a fibrin clot. many drugs used to treat cancer suppress bone marrow function and therefore the production of platelets.

Esophagogastroduodenoscopy (EGD) : esophagus varices grade 1-2 portal hypertensive gastropathy, severe.
 ASSESSMENT NURSING INFERENCE PLAN OF INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS CARE
Subjective Data: Risk for In portal Short Term 6. Determine the patient’s health 6. Early identification of possible risks Short Term Goal:
The patient bleeding hypertension, Goal: history for signs that can be associated for bleeding provides a foundation for Within 2 hours of
complained related to collateral Within 2 hours with a risk for bleeding such as liver implementing appropriate preventive nursing
dizziness, presence of circulation of nursing disease, inflammatory bowel disease, measures. interventions,
weakness and esophageal develops in the interventions, or peptic ulcer disease. 7. Hypotension and tachycardia are the client was able
presence of blood varices. lower the client will 7. Monitor patient’s vital signs, initial compensatory mechanisms to report no
in vomitus. esophagus as not especially BP and HR. usually noted with bleeding. experience in
. venous blood, experience 8. Evaluate the patient’s use of any 8. Drugs that interfere with clotting bleeding as
“Nanghihina po which is bleeding as evidenced by a
medications that can affect hemostasis mechanisms or platelet activity
ako at nahihilo. diverted from evidenced by blood pressure
(e.g, anticoagulants, salicylates, NSAIDs, increase risk for bleeding.
Nagsusuka po ako the GI tract and a blood within the normal
or cancer chemotherapy). 9. These laboratory tests provide
at may konting spleen pressure range, no
9. Review laboratory results for important information about the
dugo po na because of within the presence of blood
kasama sa suka portal normal range, coagulation status as appropriate: patient’s coagulation status and in the vomitus,
ko.” obstruction, no presence platelet count. bleeding potential. stable hematocrit
seeks an of blood in the 10. Monitor hematocrit (Hct) and 10. When bleeding is not visible, and hemoglobin
outline. vomitus, hemoglobin (Hgb). decreased Hgb and Hct levels may be levels.
Because of stable an early indicator of bleeding.
Objective Data: excessive hematocrit and
T: 37 C intraluminal hemoglobin Long Term Goal:
PR: 83 bpm pressure, these levels. DEPENDENT/ COLLABORATIVE: The client reported
RR: 10 cpm collateral veins Educate the at-risk patient about DEPENDENT/ COLLABORATIVE: no bleeding and
BP:90/60 mmHg become Long Term precautionary measures to prevent Information about precautionary have a blood
O2 Sat.: 95% tortuous, Goal: tissue trauma or disruption of the measures lessens the risk for pressure within the
dilated, and The client is normal clotting mechanisms. bleeding. normal range and
Lab work shows fragile. They expected to no presence of
Hemoglobin level are prone to have no When laboratory values are abnormal, Blood product transfusions replace blood in the
@ 7.4 g/dl ulceration and bleeding and administer blood products as blood clotting factors; RBCs increase vomitus.
hemorrhage. have a blood prescribed. oxygen-carrying capacity; FFP replaces The client was
EGDfindings: Rupture of pressure clotting factors and inhibitors; able to fully
presence of esophageal within the Educate the patient and family understand and
platelets and cryoprecipitate provide
esophageal varices is the normal range implement
members about signs of bleeding that proteins for coagulations.
varices. most common and no measures to
need to be reported to a health care
cause of death presence of prevent and
provider. Early evaluation and treatment of
of clients with blood in the recognize signs of
hepatic bleeding by a health care provider
vomitus. bleeding
cirrhosis. Inform the patient to check the color reduce the risk for complications from
The client will interventions.
and consistency of stools. blood loss.
be able to
fully
Educate the patient about over-the- Bright red blood in the stools is an
understand
and counter drugs and avoid products that indicator of lower gastrointestinal
contain aspirin or NSAIDs such as bleeding. Stool that has a dark
implement ibuprofen and naproxen. greenish-black color and a tarry
measures to consistency is linked with upper
prevent and gastrointestinal bleeding.
recognize
signs of hese drugs not only decrease normal
bleeding platelet aggregation but also decrease
interventions. the integrity of gastric mucosa
through inhibition of cyclooxygenase
(COX)-1 inhibitor and therefore
increase the risk for gastrointestinal
bleeding.