Nursing Related Learning Experience Manual

NURSING CARE PLAN

Name of Patient Mrs. Quorona Vid Rm/Bed No. 2C 204 Age 60 Chief Complaints epigastric pain
Address General Santos City Admission Date 7 / 15 / 2020 Sex F Diagnosis

ASSESSMENT HEALTH NURSING DIAGNOSIS DESIRED OUTCOME INTERVENTION EVALUATION REMARKS

PATTERN
Subjective Cues: C Note: Use P-E-S format General Objective Independent Goal was met
O client
*“I have had bad Acute pain r/t acid reflux
G Within 24 hours of * Acknowledge reports of pain satisfactory
stomach pains for N as manifested by aching control pain and
nursing intervention immediately.
about 6 weeks” I epigastric pain, fairly verbalize relief
patient describes
T continuous, and worse at from pain
satisfactory pain Rationale: One’s perception of time may
* heart burn I night and the abdomen is
control and patient become distorted during painful
V soft and tender to
identifies personal experiences. Pain can be aggravated with
E palpation in the
* aching epigastric triggers to avoid having anxiety and fear especially when pain is
pain, fairly epigastrium and heartburn
P acid reflux delayed. An immediate response to reports
continuous, and E of pain may decrease anxiety in the
worse at night R patient.
Background Knowledge
C
* It radiates to her E Specific Objectives * Assess for heartburn.
Acute pain is defined as an
back when she lies P unpleasant sensory and
down T * Client will report Rationale: Heartburn is the most common
emotional experience pain is relieved.
U feature of GERD. This becomes more
A arising from actual or
*The pain gets potential tissue damage or severe with vigorous exercise, bending, or
progressively worse L * Patient uses
described in terms of such lying down.
pharmacological and
P damage (International nonpharmacological
* take Association for the Study * Hot or cold compress
A pain-relief strategies.
acetaminophen T of Pain); sudden or slow
once- sometimes T onset of any intensity from Rationale: Heat decreases pain
twice- daily * Patient displays through improved blood blow to the area
E mild to severe with an
R improvement in mood, and through reduction of pain reflexes.
anticipated or predictable coping.
N end and a duration of less Cold lessens pain and muscle spasticity by
than six (6) months. The decreasing the release of pain-inducing
chemicals and regulating the conduction of
College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY
 Nursing Related Learning Experience Manual

unpleasant feeling of pain impulses.

pain is highly subjective in
nature that may be * Get rid of additional stressors or sources
Objective Cues
experienced by the patient. of discomfort whenever possible.
* the abdomen is soft Acute Pain serves a
and tender to protective function to Rationale: Patients may experience an
palpation in the make the patient informed exaggeration in pain or a decreased ability
epigastrium and knowledgeable about to tolerate painful stimuli if environmental,
the presence of an injury intrapersonal, or intrapsychic factors are
* span of liver or illness. A burning pain further stressing them.
dullness is 13cm over or discomfort that may
the MCL splenic * Provide rest periods to promote relief,
move from your stomach
dullness at the 10th
to your abdomen or chest, sleep, and relaxation.
intercostal space
(ICS) or even up into your
throat. Regurgitation: a Rationale: One’s experiences of pain may
* slight midline sour or bitter-tasting acid become exaggerated as a result of
pulsation, in the backing up into your exhaustion. Pain may result in fatigue,
epigastrium throat or mouth. which may result in exaggerated pain. A
peaceful and quiet environment may
Ref. facilitate rest.
https://nurseslabs.com/acute
-pain/ Dependent

Administered medication as ordered:

Foaming agents (Gaviscon)

*Rationale: coat your stomach to

prevent reflux.
 
*H2 blockers (Pepcid, Tagamet)

Rationale: slow acid production.

* Proton pump inhibitors (Aciphex,

Nexium, Prilosec, Prevacid, Protonix)

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

 Nursing Related Learning Experience Manual

Rationale: lessen the amount of acid your

stomach makes.

*Refer to the gastroenterologist

Rationale: This will help the clients

present health concern because
gastroenterologist are the doctors who
treats diseases of the stomach and
intestines

ASSESSMENT HEALTH NURSING DIAGNOSIS DESIRED OUTCOME INTERVENTION EVALUATION REMARKS

PATTERN

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

 Nursing Related Learning Experience Manual

Read the following case study. Then work through the steps of analysing the case study data.

First identify abnormal data and strengths in subjective and objective findings;
* The abdomen is soft and tender to palpation in the epigastrium
* Span of liver dullness is 13cm over the MCL splenic dullness at the 10 th intercostal space (ICS)
* Slight midline pulsation, in the epigastrium
*“I have had bad stomach pains for about 6 weeks”
* Heart burn
* aching epigastric pain, fairly continuous, and worse at night
* It radiates to her back when she lies down
*The pain gets progressively worse
* take acetaminophen once- sometimes twice- daily
* Mild nausea
* relates loss of appetite
* it also wakes her up at night

Assemble cue clusters;

* The abdomen is soft and tender to palpation in the epigastrium
* Span of liver dullness is 13cm over the MCL splenic dullness at the 10 th intercostal space (ICS)
* Slight midline pulsation, in the epigastrium
*“I have had bad stomach pains for about 6 weeks”
* Heart burn
College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY
 Nursing Related Learning Experience Manual

* aching epigastric pain, fairly continuous, and worse at night

* It radiates to her back when she lies down
*The pain gets progressively worse
* take acetaminophen once- sometimes twice- daily
* Mild nausea
* relates loss of appetite
* it also wakes her up at night

Draw inferences;
*Imbalance nutrition: less than body requirements

* Acute pain
*Disturbed sleep pattern

Make possible nursing diagnoses;

* Acute pain r/t acid reflux as manifested by aching epigastric pain, fairly continuous, and worse at night and the abdomen is soft and tender to palpation in the epigastrium
and heartburn
* Imbalance nutrition: less than body requirements r/t pain as manifested by mild nausea and relates loss of appetite
* Disturbed sleep pattern r/t pain and discomfort as manifested wakes her up at night

Identify defining characteristics;

* The abdomen is soft and tender to palpation in the epigastrium
* Span of liver dullness is 13cm over the MCL splenic dullness at the 10 th intercostal space (ICS)
* Slight midline pulsation, in the epigastrium
*“I have had bad stomach pains for about 6 weeks”
* Heart burn
* aching epigastric pain, fairly continuous, and worse at night
* It radiates to her back when she lies down
*The pain gets progressively worse

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

 Nursing Related Learning Experience Manual

* take acetaminophen once- sometimes twice- daily

* Mild nausea
* relates loss of appetite
* it also wakes her up at night

Confirm or rule out the diagnoses; and

*NCP
Document your conclusions.
*NCP

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY