NURSING CARE PLAN FOR HIATAL HERNIA

ASSESSMENT NURSING INFERENCE PLAN OF INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS CARE
Subjective Data: Risk for Dyspnea and Short Term 1. Monitor respiratory rate, depth, 1. Signs of aspiration should be Short Term Goal:
The patient aspiration coughing are Goal: and effort. Note any signs of detected as soon as possible Within an hour of
complained of related to caused by aspiration such as dyspnea, to prevent further aspiration nursing
frequent recurrent gastric acids Within an hour cough, cyanosis, wheezing, or and to initiate immediate interventions,
regurgitation after regurgitation that have of nursing fever. treatment. the client was able
meals and of gastric entered the interventions, 2. Auscultate for lung sounds 2. To determine presence of to demonstrate
vomiting of blood. contents lungs. The the client will 3. Assess patient’s ability to secretions in the lungs. relief from dyspnea
“Maasim ang regurgitation of demonstrate swallow and the presence 3. Loss of the gag reflex and coughing. The
panlasa ko at gastric acids relief from of gag reflex. increases the risk of client was able to
mahapdi sa cause swelling dyspnea and 4. Avoid placing patient aspiration. experience less
lalamunan ang of the airways coughing. The in supine position, have the 4. Supine position after meals and clear
pakiramdam. and stimulates client will also patient sit upright after meals. can increase regurgitation of regurgitation of
Nauubo ako dahil coughing experience 5. Elevate HOB while in bed.. acid. gastric acids.
may mahapdi sa reflex. less and clear 6. Instruct the patient to chew food 5. To prevent aspiration by
lalamunan ko. May regurgitation thoroughly and eat slowly. preventing the gastric acid to
konting dugo din of gastric 7. Assist/instruct in relaxation flow back in the esophagus.
po sa suka ko.” acids. techniques, e.g., deep/slow 6. Well-masticated food is easier
breathing to swallow. Food should be cut Long Term Goal:
Long Term into small pieces.
Objective Data: Goal: DEPENDENT/ COLLABORATIVE: 7. Helpful in decreasing The client was
T: 36.5 C discomfort and difficulty in able to reduce the
PR: 83 bpm The client will 8. Administer Antacids as ordered. breathing. risk of aspiration
RR: 10 cpm be able to 9. Instruct patient to avoid highly as evidenced by
BP:120/80 mmHg reduce the seasoned food, acidic juices, DEPENDENT/ COLLABORATIVE: effective breathing
O2 Sat.: 95% risk of alcoholic drinks, bedtime 8. To minimize gastric and no coughing
aspiration as snacks, and foods high in fat. hyperacidity and minimize within 2 days of
Patient is observed evidenced by episodes of regurgitations. nursing
with discomfort, effective 9. These can reduce the lower interventions. The
dyspnea and breathing and esophageal sphincter pressure client also
coughing. no coughing and decrease the production experienced no
within 2 days of gastric acids. regurgitation of
of nursing gastric acids.
interventions.
The client will
also
experience no
regurgitation
of gastric
acids
 ASSESSMENT NURSING INFERENCE PLAN OF INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS CARE
Subjective Data: Acute pain Short Term 1. Assess for heartburn. 1. To determine the presence of Short Term Goal:
The patient related to Goal: (characteristic, severity, GERD. Heartburn is the most
complained of irritation in frequency) common feature of GERD. Within an hour of
regurgitation of the Within an hour 2. Carefully assess pain location 2. Pain of esophageal spasm nursing
acid and esophageal of nursing and discern pain from GERD resulting from reflux interventions,
heartburn. mucosa as interventions, and angina pectoris. esophagitis tends to be the client was able
evidenced by the client will 3. Avoid placing patient chronic and may mimic angina to report relief from
“Maasim ang regurgitation report relief in supine position, have the pectoris: radiating to the neck, pain as evidenced
panlasa ko at of acid and from pain as patient sit upright after meals. jaws, and arms. by a decrease in
mahapdi sa heart burn. evidenced by 4. Elevate HOB while in bed.. 3. Supine position after meals the rating of chest
lalamunan ang a decrease in 5. Instruct the patient to chew food can increase regurgitation of pain by 7/10 to
pakiramdam. the rating of thoroughly and eat slowly. acid. 5/10.
Nauubo ako dahil chest pain by 6. Assist/instruct in relaxation 4. To prevent aspiration by
may mahapdi sa 7/10 to 5/10. techniques, e.g., deep/slow preventing the gastric acid to Long Term Goal:
lalamunan ko. breathing flow back in the esophagus.
Mainit at masakit Long Term 5. Well-masticated food is easier The client was
ang pakiramdam Goal: to swallow. Food should be cut able to feel
sa dibdib ko. DEPENDENT/ COLLABORATIVE: into small pieces. relieved from pain
Nararamdaman ko The client will 7. Administer Antacids as ordered. 6. Helpful in decreasing and did not
din ang sakit sa be relieved 8. Instruct patient to avoid highly discomfort and difficulty in experience
may braso ko.” from pain and seasoned food, acidic juices, breathing. heartburn and
will not alcoholic drinks, bedtime regurgitation within
experience snacks, and foods high in fat 2 days of nursing
Objective Data: heartburn and . DEPENDENT/ COLLABORATIVE: interventions.
T: 36.5 C regurgitation 7. To minimize gastric
PR: 83 bpm within 2 days hyperacidity and minimize
RR: 10 cpm of nursing episodes of regurgitations and
BP:120/80 mmHg interventions. heartburn
O2 Sat.: 95% 8. These can reduce the lower
esophageal sphincter pressure
Patient is observed and decrease the production
with discomfort of gastric acids.
and guarding
behavior in the
chest.

Pain Scale of 7/10.

 ASSESSMENT NURSING INFERENCE PLAN OF INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS CARE
Subjective Data: Knowledge Limited health Short Term 1. Assess patient for information 1. Provides a basis for patient Short Term Goal:
“Hindi ko alam deficit related literacy skills Goal: needed and ability to perform teaching.
kung bakit laging to lack of are often actions independently. 2. Provides knowledge and Client did not
samasakit ang information greater among Client will 2. Provide patient with information facilitates compliance. experience heart
sikmura at dibdib regarding certain groups; have an regarding disease 3. Gravity helps control reflux burn and
ko pagkatapos condition/dis older adults, increased process, health practices that and causes less irritation from regurgitation after
kumain.” as ease process people with knowledge can be changed, and reflux action into the 2 hours of nursing
verbalized by the as evidenced limited regarding medications to be utilized. esophagus. interventions.
patient. by presence education, actions 3. Instruct patient regarding eating 4. Promotes comfort by
of minority preventing the small amounts of bland food the decrease in Long Term Goal:
preventable population. occurrence of followed by a small amount of intra-abdominal pressure,
complication Clients with low heart burn water. Instruct to remain in which reduces the reflux of The client showed
s. literacy skills and upright position at least 1–2 gastric contents. full understanding
have less regurgitation hours after meals, and to avoid 5. Helps prevent reflux. and implemented
information after 2 hours eating within 2–4 hours of 6. These food items increase ways to prevent
about health of nursing bedtime. acid production that the occurrence of
promotion interventions. 4. Instruct patient to avoid bending precipitates heartburn and heart burn and
and/or over, coughing, straining at increased reflux. regurgitation after
management of Long Term defecations, and other activities 7. Promotes knowledge, 2 hours of nursing
a disease Goal: that increase reflux. facilitates compliance with interventions.
process for 5. Instruct patients to eat slowly, treatment, and allows for
themselves. The client will chew foods well and maintain a prompt identification of
be able to fully high-protein, low-fat diet. potential need for changes in
understand 6. Instruct patient to avoid medication regimen to prevent
and temperature extremes of food, complications.
implement the spicy foods, and citrus, and gas
ways to forming foods.
prevent the 7. Instruct patient in medications,
occurrence of effects, side effects, and to
heart burn report to physician if symptoms
and persist
regurgitation despite medication treatment.
after 2 hours
of nursing
interventions.