XIV.

NURSING CARE PLAN NURSING CARE PLAN 1: ACUTE PAIN ASSESSMENT Subjective: Sumasakit pa din yung sa may tiyan ko as verbalized by the patient. Objective: Facial grimace Guarding behaviour Weakness and limited movement Pain scale 3/10 Vital signs: Temperature = 36.8C Pulse Rate = 72bpm Respiratory Rate = 19 cpm Blood Pressure = 110/60 mmHg NURSING DIAGNOSIS Pain related to abdominal condition (ulcer like dyspepsia) as manifested by positive facial grimace, guarding behaviour, weakness and limited movement and a verbal report of abdominal discomfort, 3/10. PLANNING After 2 hour of nursing interventions, the patient will be able to report that the pain is relieved that can be evidenced by a pain scale of at least 0-2 out of ten. IMPLEMENTATIO N Independent: 1. Provided quiet and comfortable environment. 2. Encouraged diversional activities (watch TV, read newspaper, and listen to relaxing music). 3. Encouraged adequate rest periods. 4. Instructed patient to perform cold compress as indicated. RATIONALE Independent: 1. To promote relaxation and reduce tension. 2. To divert the attention of patient from the pain. EVALUATION After 2 hours of nursing interventions, the goal was met, the patient was relieved from her pain as evidenced by the following: Kirot- kirot na lang kapag nagalaw ako, 1 out of 10 na lang as verbalized by the patient.

3. To prevent fatigue. 4. To promote vasoconstriction that promotes analgesic effect thus reduces pain. 5. To help reduce precipitating factors that may cause or increase pain.

5. Discussed with SO(s) ways in which they can assist client 12

Dependent: 1. Administered Omeprazole 40 mg IV OD, as ordered. Collaborative: 1. Reminded patient to follow soft diet as prescribed by dietician.

Dependent: 1. Omeprazole reduces gastric pain. Collaborative: 1. To reduce gastric workload.

Table No. 6. Nursing Care Plan for Acute Pain NURSING CARE PLAN 2 : SLEEP DEPRIVATION ASSESSMENT Subjective: Hindi pa ako nakakatulog, gusto ko matulog as verbalized by the patient. Objective: Dark circles under the eyes Weakness NURSING DIAGNOSIS Sleep deprivation related to abdominal discomfort secondary to underlying condition (ulcer like dyspepsia) as manifested by positive drowsiness, weakness, dark PLANNING After 8 hours of nursing interventions the patient will be able to report improved sleep that can be evidenced by a 23 hour sleep within the shift. IMPLEMENTATIO N Independent: 1. Instructed patient to avoid caffeinated substances/ foods. 2. Provided calm environment. 3. Adjusted lightings to dim. 13 RATIONALE Independent: 1. Caffeine properties inhibit sleep. 2. For more conducive place for sleep. 3. To relax the eyes of patient EVALUATION After 8 hours of nursing interventions the goal was met, the patient was able to report improved sleep as evidenced by the following: Nakatulog ako kanina 9- 12 (3 hours), okay na

Drowsy Pain scale = 3/10 Vital signs: Temperature = 36.8C Pulse Rate = 72bpm Respiratory Rate = 19 cpm Blood Pressure = 110/60 mmHg

circles under the eyes and a verbal report of desire to sleep.

4. Reduced noise in the room as much as possible (decrease volume of TV, requested visitors to keep their voice down). 5. Promoted physical activities the next day during day time. 6. Positioned patient comfortable. 7. Instructed patient to leave cold compress while sleeping. Dependent: 1. Administered Omeprazole 40 mg IV OD, as ordered. Collaborative: 1. Collaborated with sleep specialist as appropriate. 14

and thus promote sleep. 4. To promote sleep.

naman, nakapahinga kahit papaano as verbalized by the patient.

5. To increase desire to sleep. 6. To reduce discomfort. 7. To continue the reduction of pain this inhibits the sleep of the patient. Dependent: 1. Omeprazole reduces gastric pain that causes sleep disturbance. Collaborative: 1. To have proper and individualized intervention for

the condition of the client. Table No. 7. Nursing Care Plan for Sleep deprivation

NURSING CARE PLAN 3: RISK FOR IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS ASSESSMENT Risk Factors: Subjective: Ayoko kumain nd madami, natatakot ako baka sumakit ulit ng grabe ang tiyan ko as verbalized by the patient. Objective: Food aversion Consumes 25% of food in tray both breakfast and lunch time. Weakness Height = 1.68m Weight= 63 kg BMI= 22 (Normal) NURSING DIAGNOSIS Risk for imbalanced nutrition: less than body requirements related to self impose decrease intake probably secondary to abdominal discomfort. PLANNING Short term goal: After 4 hours of nursing interventions the patient will be able to verbalize the use of 2-3 behaviours that prove understanding of the importance of good eating habits. IMPLEMENTATIO N Independent: 1. Explained and encouraged good eating habits to patient. 2. Encouraged increase oral food intake, and fibers and not fluids to patient. 3. Emphasized importance of wellbalanced food intake. 4. Taught patient to avoid food that are acidic in nature. 15 RATIONALE Independent: 1. Promote awareness of the importance of good nutrition. 2. To promote adequate nutrition and roughage. 3. To prevent imbalances. 4. Acidic foods increase gastric acidity that can contribute to pain. EVALUATION Short term goal: After 4 hours of nursing interventions the goal was met, the patient was able to verbalize behaviours that proves understanding of the importance of good eating habits as evidenced by Kahit pakontikonti ang kain, kasi mas sasakit nga kapag gutom, tsaka bawas sa tubig muna para hindi agad

Basis of Interpretation: BMI of < 18.5 is classified as Underweight BMI of 18.5 to 24.9 is classified as Normal BMI of 25 to 29.9 is classified as Overweight BMI of 30 to 39.9 is classified as Obesity

Long term goal: After 24 hours, the patient will be able to demonstrate good eating habits as evidenced by consumption of 50% - 75% of her food in the food tray.

5. Encouraged small frequent feedings, if abdominal pain persists. Dependent: 1. Administered HNBB amp IV every 8 hours, as ordered. Collaborative: 1. Reminded patient to follow soft diet as prescribed by dietician.

5. To prevent early satiety.

mabusog as verbalized by the patient. Long term goal: After 24 hours, the patient was able to demonstrate good eating habits as evidenced by the following: Negative for weakness Patient consumed 75% each of her food tray for breakfast and lunch respectively.

Dependent: 1. To prevent pain while eating. Collaborative: 1. To reduce gastric workload.

Table No. 8. Nursing Care Plan for Risk for Imbalanced Nutrition: less than body requirements NURSING CARE PLAN 4: READINESS FOR ENHANCED THERAPEUTIC REGIMEN MANAGEMENT ASSESSMENT Subjective: Okay na naman ang pakiramdam ko as verbalized by the patient. NURSING DIAGNOSIS Readiness for enhanced therapeutic regimen management PLANNING After 8 hours of nursing interventions the patient will be able to remain IMPLEMENTATIO N Independent: 1. Accepted patients evaluation of own strengths and 16 RATIONALE Independent: 1. Promotes sense of self esteem and confidence to EVALUATION After 8 hours of nursing interventions the goal was met, the patient was able

related to free of Objective: underlying preventable Patient signed the condition (ulcer complications and informed consent like- dyspepsia) progression of Sense of as manifested by illness and willingness cooperativeness sequelae as Cooperative and willingness to evidenced by at Positive Progress: all therapeutic least one of the Decreased pain interventions and following absence and discomfort procedures. of pain, infection and demonstrate vital signs maintained within the normal range.

limitations while working together to improve abilities. 2. Acknowledged individual efforts and capabilities to reinforce movement toward attainment of desired outcome. 3. Promoted patient and caregiver choices and involvement in planning for and implementing added tasks and responsibilities. 4. Assisted in implementing strategies for monitoring progress and responses to therapeutic management (like keeping a logbook) 5. Discussed present resources 17

continue effort.

2. Provides positive reinforcement encouraging continued progress toward desire goals. 3. Better to include family in planning.

to remain free of preventable complications and progression of illness and sequelae as evidenced by: Wala nang masakit sa akin ngayon, zero na over ten as verbalized by the patient. Vital signs: Temperature = 37C Pulse Rate =84bpm Respiratory Rate = 20 cpm Blood Pressure = 110/60 mmHg

4. To note any differences.

5. To note if changes can be managed or

used by the patient. Dependent: 1. Encouraged to maintain her compliance with her medication, as ordered. Collaborative: 1. Reminded patient to follow soft diet as prescribed by dietician.

arranged. Dependent: 1. To have a continues positive progression of disease. Collaborative: 1. To reduce gastric workload.

Table No. 9. Nursing Care Plan for Readiness for enhanced therapeutic regimen management

NURSING CARE PLAN 5: DEFICIENT KNOWLEDGE ASSESSMENT Subjective: Ano ba yung gasgas daw sa sikmura ko? as verbalized by the patient. Objective: NURSING DIAGNOSIS Deficient knowledge related to unfamiliarity with information resource as manifested by positive PLANNING IMPLEMENTATI ON Independent: RATIONALE Independent 1. Information can decrease anxiety, thereby reducing sympathetic stimulation. EVALUATION After 8 hours of nursing interventions, the patient was able to understand her condition as evidenced by:

After 8 hours of nursing interventions, 1. Provided the patient will explanations be able to of/reasons for test verbalize procedures and understanding of preparation her condition. needed. 18

Asking questions Weakness Poor eating habits Colonscopy Report: Gastric erosion at antrum

weakness, poor eating habits, patient asking questions and colonoscopy report revealed presence of gastric erosion at antrum.

2. Reviewed disease process/prognosis .

2. Provides knowledge base from which patient can make informed choices. 3. Effective communication and support at this time can diminish anxiety and promote healing. 5. To gain knowledge that it promotes flow of food and general relaxation during initial digestive process. 6. For her to have an idea that it promotes gas formation, which can increase gastric distension/discomf ort. Collaborative: 1. To reduce gastric workload.

3. Encouraged questions, expression of concern

Sa pagkain ko pala ang pinaka importanteng bagay ngayon sa sakit ko, magaagahan na ako at magbabawas ng kape, baka lumala pa yung sakit ko sa sobrang kapabayaan ko as verbalized by the patient.

5. Instructed the importance of positioning, resting in semiFowlers position after meals. 6. Taught client to limit gum chewing, sucking on straw/hard candy, or smoking Collaborative: 1. Reminded patient to follow soft diet as prescribed by 19

dietician. Table No. 10. Nursing Care Plan for Deficient knowledge XV. DRUG STUDY DRUG STUDY: OMEPRAZOLE GENERIC NAME (BRAND NAME) Omeprazole (Risek) ROUTE Intravenous DOSAGE 40 mg once a day INDICATIONS/ CONTRAINDICATIO NS Indications: Treatment of duodenal cancer, gastric ulcer, H. Pylori associated with peptic ulcer disease, reflux esophagitis. SIDE EFFECTS/ ADVERSE EFFECTS Side effects: Headache, diarrhea, constipation, NURSING CONSIDERATIO NS 1. Take medication immediately before a meal. 2. Report any changes in urinary elimination such as pain or discomfort associated with urination, or blood in urine. 3. Report severe diarrhea; drug may need to be discontinued. 4. Do not breast feed while taking this drug.

Contraindications: Hypersensitivity to substituted benzimidazoles.

Adverse Effects: Abdominal pain, nausea, vomiting and flatulence.

20

Table No. 11. Drug Study for Omeprazole DRUG STUDY: HNBB GENERIC NAME (BRAND NAME) Hyoscine-Nbutylbromide (Risek) ROUTE Intravenous DOSAGE 1 ampule every 8 hours INDICATIONS/ CONTRAINDICATIO NS Indications: Acute GI, biliary, genitourinary spasm, including biliary renal colic, Also as an aid in diagnostic and therapeutic procedures like gastroduodenal endoscopy. Contraindications: Buscopan Tablets should not be administered to patients with myasthenia gravis, megacolon and narrow angle glaucoma. In addition, they should not be given to patients with a known hypersensitivity to hyoscine-Nbutylbromide or any 21 NURSING CONSIDERATIO NS 1. Drug compatibility should be monitored closely in patients requiring adjunctive therapy. 2. Avoid driving & operating Adverse Effects: machinery after Abdominal pain, parenteral nausea, vomiting administration. and flatulence. 3. Avoid strict heat 4. Raise side rails as a precaution because some patients become temporarily excited or disoriented and some develop amnesia or become drowsy. 5. Reorient patient, as SIDE EFFECTS/ ADVERSE EFFECTS Side effects: Headache, diarrhea, constipation,

other component of the product

needed, Tolerance may develop when therapy is prolonged Atropine-like toxicity may cause dose related adverse reactions. 6. Keep emergency equipment available

Table No. 12. Drug Study for HNBB

22