Actual Nursing Care Plan

Assessment Data
SUBJECTIVE

Nursing Diagnosis

Goals and Objectives

Nursing Intervention and Rationale

Assess for signs and symptoms of G.I bleeding. Check for secretions. Observe color and consistency of stools or vomitus. Observe for presence of petechiae, ecchymosis, bleeding from one more sites. Monitor pulse, Blood pressure. Note changes in mentation and level of consciousness.

Evaluation

Assessment Data

After 1 hr. Of nursing sumuka at Injury, risk for interventions, the client will tumae ako nang hemorrhage be able to dugo as related to verbalized by altered clotting demonstrate behaviors the patient factor. that reduce the risk for bleeding.

OBJECTIVE Weakness Irritability Hematemesi s Blood in stool

After 1 hr. Of nursing The G.I tract interventions, the client (esophagus and was able to demonstrate rectum) is the most behaviors that reduce the usual source of bleeding of its mucosal risk for bleeding. fragility. Sub-acute Disseminated intravascular coagulation (DIC) may develop secondary to altered clotting factors. An increase in pulse with decreased blood pressure can indicate loss of circulating blood volume.

Changes may indicate Cerebral perfusion secondary to hypovolemia, hypoxemia.

Actual Nursing Care Plan

Assessment Data
SUBJECTIVE At the end of 8 hrs of duty, client will ayaw ko nang Altered verbalize kumain, kasi Nutrition: Less understanding of sinusuka ko than Body nutritional needs. lang as Requirements verbalized by related to Establishes the patient inadequate a dietary pattern food with caloric intake/vomiting intake adequate to regain appropriate OBJECTIVE weight. pale skin poor skin turgor decreased appetite irritabilty

Nursing Diagnosis

Goals and Objectives

Nursing Intervention and Rationale

Establish a minimum weight goal, and daily nutritional requirements. Maintain a regular weighing schedule make selective menu available, and allow patient to control choices as much as possible Administer nutritional therapy with in a hospital treatment program as indicated Provide diet and snacks with substitutions of preferred foods as indicated

Evaluation

Assessment Data

Malnutrition is a mood- After 8 hr. Of nursing interventions, the client altering condition leading to depression was able to verbalized understanding of and agitation and nutritional needs and affecting cognitive established a dietary function. pattern with caloric intake Provides accurate adequate to regain ongoing record of weight loss and/or gain appropriate weight. patient needs to gain confidence in self and feel in control of environment and is more likely to est preferred foods. Cure of the underlying problem cannot happen without nutritional status. Having a variety if foods available will enable the patient to have a choice of potentially enjoyable foods.

Actual Nursing Care Plan

Assessment Data
SUBJECTIVE

Nursing Diagnosis

Goals and Objectives

At the end of 2 days duty, patient will be able to;

Nursing Intervention and Rationale

Perform comprehensive assessment pain Reduce or eliminate factors that precipitate pain Teach the use of non-pharmacologic techniques(relaxatio n,music therapy,guided imagery) Medicate before an activity to increase participation Administer pain reliever as indicated

Evaluation

Assessment Data

masakit ang tyan Acute Pain ko twing related to gumagalaw ako disease as verbalized by process the patient.

Pain is subjective At the end of 2 days duty, patient verbalized that she is experience and must be describe by no longer felt the pain client Personal factors can influence pain and pain tolerance The use of noninvasive relief measures can increase the release of endorphins and enhance the therapeutic effect of pain relief medications. Timing and ambulation activities will enhance if pain is controlled or tolerate. Relieves pain

Verbalize that pain is completely gone/relieved. Demonstrate therapeutic methods to relieve pain Absence of the use of accessory muscles

OBJECTIVE Restlessnessnoted Pain scale-6 Guarding behavior Use of facial grimace