NURSING CARE PLAN

ASESSMENT NURSING SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS RATIONALE
Acute Pain related h.pylori HCL Long Term: Independent: Long Term:
to gastric acid  Monitor pain
Subjective: stress After of 2 weeks of  To have a After of 2 weeks of
secretion as scale of the
nursing baseline data nursing
“Sumasakit ang evidenced by pain mucosal injury client
interventions the interventions the
tiyan ko,” as scale of 7/10 client will be able client was able
verbalized  Demonstrate
decrease of host reduced pain by  It enhance reduced pain by
Objective: 7/10 to 3/10. non- 7/10 to 3/10.
defense client’s comfort
pharmalogical
Short Term: and relaxation Short Term:
management
 cramping pain After 2 hours of - Music After 2 hours of
increase NH3
nursing Therapy nursing
 pain scale of - Massage
interventions the  It can irritate the interventions the
7/10
client will be able  Encourage client was able to:
stomach by
 tenderness of to: patient to avoid increasing HCL
RLQ damage epithelial alcoholic
cell beverages and  Verbalized non
 restlessness
 Verbalized non cigarettes of phamalogical
phamalogical coffee  To prevent activities injury
decrease efficacy
activities injury  Encourage further fatigue.  Demonstrate at
of mucosal
 Demonstrate at adequate rest least 3 lifestyle
defense
least 3 lifestyle period  To promote changes
changes  Demonstrate comfortable
adhesion of comfortable position
h.pylori positions  to prevent
-Sim’s positions secretion of
 Instruct the cathecho-
inflammation client to lamins and
reduced stress cortisol that
induce HCL
pain Collaborative  It interferes with
  Instruct patient secretion of
to take drugs gastric acid
-Harrison Medical
Book 17th edition as prescribed
by the
physician
Antacid, h2
blocker,  To relieve from
coating agents pain
 Mefenamic
Acid 250 mg,  Modification from
PO the diet may
 DIET: prevent further
Consult irritation and
nutritionist for inflammation that
further cause peptic
prescribed ulcer
diet.
However,
avoid,
alcoholic,
caffeinated,
and smoking

NURSING CARE PLAN

ASESSMENT NURSING SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS RATIONALE
Risk for Ineffective
Altered lung Long Term: Independent: Long Term:
Breathing Pattern defense  Maintain calm
Subjective: After of 2 weeks of  To limit level of After of 2 weeks of
 related to smoking
“Nahihirapan nga nursing attitude of the anxiety nursing
ako minsan,” as as evidenced of interventions the client interventions the
verbalized RR of 26cpm client will be able client was able
-deceased cough have normal  Instruct client to  To promote lung have normal
Objective: effectiveness respiratory pattern perform deep expansion respiratory pattern
-decreased of 16-20 breathing of 16-20
 RR: 26 mucocilliary Short Term: exercises Short Term:
function  It can promote
 asymmetrical After 2 hours of  demonstrate lung expansion After 2 hours of
chest -altered mucus nursing and breathing of nursing
diaphragmatic
expansion interventions the breathing the client. interventions the
client will be able client was able to:
 presence of Impaired gas -lie in supine
to: position, inhale
cough exchange
and exhale
 crackles sound  Cigarettes are  Verbalized 3
slowly
upon  Verbalized 3 main cause why causative
Increase close  Encourage client
auscultation causative the client has factors
volume to reduce or
factors DOB. It  Demonstrate at
avoid used of
 Demonstrate at decreases the least 3
cigarettes
least 3 cilliary action of techniques for
Irregular breathing
techniques for the lungs. coping
pattern
coping behaviors
behaviors
 Encourage
exercise  To promote
 Provide health breathing pattern
Ref: Medical
Surgical page 626 teachings about  To provide
the ff: information and
-smoking: cause to encourage
and effect client to avoid
taking cigarettes
Collaborative
 use nebulizer  ventilatory
q8 as support might
prescribed by be needed
the physician