ASSESSMENT DIAGNOSIS RATIONALE PLANNING IMPLEMENTATION RATIONALE EVALUATION

S>Yung sugat na to
ay nung last year
lang para ma-
operaha ang tiyan
ko kasi may cancer
ako.

O>
Alert, conscious,
coherent
Afebrile
Oriented to time,
place and person.
Good skin turgor
capillary refill after
2-3 seconds
muscle strength of
5/5 on both upper
and lower
extremities.
No bluish
discoloration; no
masses noted @
abdomen
w/ surgical incision
extending from L &
R upper quadrant of
abdomen; dry &
intact.
Auscultated 5-6
borborygmic sound
in each quadrant
for 1 minute.
Tympany heard @
each quadrant
w/ IVF #1 PNSS 1L
X KVO.
W/ SD #6 PNSS 1L

Disturbed body
image r/t presence
of post- surgical
incision as
evidenced by
incision @ L & R
upper area
abdomen
Gastric Carcinoma
can occur anywhere
in the stomach;
tumor infiltrates the
surrounding
mucosa,
penetrating the wall
of the stomach and
adjacent organs and
structures. The
esophagus and
duodenum are
already affected at
the time of
diagnosis. Surgery
done is total
gastrectomy.


Reference: 12
th

edition Brunner
&Suddarths
textbook of
Medical-Surgical
Nursing; pg.1056-
1060
SHORT TERM GOAL:
After 8 hours of
nursing
intervention, the
patient will be able
to understand body
changes and
verbalize
acceptance of self.

LONG TERM GOAL:
After 2-3 days of
nursing
intervention, the
patient will be able
to acknowledge self
as an individual and
does not negate
self-esteem.


INDEPENDENT:
>Monitored vital
signs.


>Assess the BMI,
weight gain or loss.

>Assess drug side
effects.


>Encouraged eating
balanced meals
modified by the
physician.
>Weigh regularly.
>Provided comfort
measures such as
touch and relaxing,
quiet and clean
environment.
>Encourage
verbalization of
feeling.
>Encourage client
to touch affected
body part.
DEPENDENT:
>Encourage family
member to increase
esteem of patient
and understanding
of situation.

Collaboration:
dietician and other
health care team.

>Establish a
baseline data and
check the patients
condition.
>Check for an
increase or
decrease in weight.
>This is to check if
this can affect the
appetite and food
intake.
>Provide nutrients
to the body and
maintain
appropriate weight.
>Monitor weight
gain or loss.
>Provide comfort
and safety and to
enhance food
intake.
>Enhance handling
of situation.

>incorporate
changes into body
image.

>To enhance self-
image of patient
without negating
self-esteem and
support from
family.

>Modify the food
and other health
SHORT TERM GOAL:
After 8 hours of
nursing
intervention, the
patient is able to
demonstrate
understanding of
situation and
verbalize slow-
acceptance of self.

LONG TERM GOAL:
After 2-3days of
nursing
intervention,
patient is able to
acknowledge self
and no negation of
self-esteem.
+ 5FU 900mg x
12hours
(chemotherapy
drug)
Latest WBC result
is 6.9 x 10^/c

BP: 120/70
T: 35.9
H: 67
R: 17
services
appropriate to the
pt.