NURSING

CARE PLAN
Gina is a 19-year old nursing student in Davao. She is known in school as an academic achiever and top
student, and is often seen reading books. She has a sensitive personality, often having meaningless grudges,
low self-esteem on her appearance, and feelings of inadequacy over the shallowest things. She cannot
communicate her thoughts well to her classmates, friends and family, which leaves them guessing on her real
feelings. Some got tired of understanding her and simply did not care anymore.

One day, the client has been diagnosed with gastric ulcer (damage to the stomach wall) after coming to the
emergency room of a public hospital. She showed signs of vomiting and severe stomach pain measuring 8 out of
10 on the pain scale, appearing thin, pale and weak. She was weighed, and it was discovered that her weight is
not appropriate for her age and height. Before arriving at the hospital, the client was explaining to the ER nurse
that she has a dietary pattern of eating twice a day with little breakfast, sometimes even without lunch, for she
spends a lot of time at the library. Her twenty-four dietary intake is made up of meats, rice, vegetables and
drinking sodas every time she feels thirsty. Prior to admission, she has not eaten for 8 hours. She was taken to
the medical-surgical ward for observation, while different diagnostic tests was ordered by the physician and
carried by the nurses. A staff nurse was tasked to interview Gina, complete her Patient History and give her
nursing care. The patient at first did not want anything to do with the nurse, saying "ayos lang po talaga ako ate",
and "wala naman pong problema talaga "
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Data: Imbalance Nutrition: SHORT TERM GOAL: Independent: Independent: After 12 hours of
Less than Body - Obtain dietary - To monitor the nursing intervention,
- verbalized “ayos Requirements related After 12 hours of history noting. dietary pattern and the patient was able
lang po talaga ako to the client’s dietary nursing intervention, to know the to:
ate” and “wala pattern of eating twice the patient will be able - Client should deviations from
naman pong a day with little to: understand the normal. - Displayed
problema talaga” breakfast, sometimes - Display individual normalization of
- severe stomach even without lunch as normalization of nutritional needs - To determine laboratory values.
pain measuring 8 evidenced by vomiting laboratory values. and ways client is informational needs
out of 10 on the and severe stomach - Reduce the signs of meeting those of client. - Reduced the signs
pain scale. pain measuring 8 out of vomiting/nausea. needs. of
10 on the pain scale, - Verbalized the - Identifies eating vomiting/nausea.
Objective Data: appearing thin, pale decreased of - Explore lifestyle practices that may
and weak. stomach pain. factors such as need to be - Verbalized the
- Thin, pale, and - Verbalize specific eating corrected and decreased of
weak body. understanding of habits, the meaning provides insight into stomach pain.
- Show signs of causative factors of food to client. dietary
vomiting and severe when known and interventions that - Verbalized
stomach pain. necessary - Emphasize may appeal to understanding of
- Inappropriate interventions. importance of well- client. causative factors
weight for her age balanced, nutritious when known and
and height. intake. - To provide necessary
- Unhealthy eating information interventions.
habits and dietary - Develop consistent, regarding individual
patterns. realistic weight goal nutritional needs THE GOAL MET!
with client. and ways to meet
these needs.
LONG TERM GOAL: - Create a health - To serve as a After 1 week of nursing
teaching plan. motivation to intervention, the
After 1 week of nursing continue the patient was able to:
intervention, the - Assess the client’s healthy eating
patient will be able to: stomach pain by habits. - Demonstrate
finding the location, progressive weight
- Demonstrate duration, - For the client to be gain toward goal
progressive weight frequency, and knowledgeable on and in accordance
gain toward goal intensity. how to manage her to her age and
and in accordance time between height.
to her age and Dependent: eating and studies.
height. - Use non- And for her to learn - Be free of signs of
- Be free of signs of pharmacological what the proper malnutrition as
malnutrition as pain relief and healthy diet is reflected in defining
reflected in measures that will for her especially characteristics.
Defining reduce the pain if she is studying.
Characteristics. ordered by the - Have a Proper and
- Have a Proper and physician. - To properly healthy dietary
healthy dietary documented the pattern.
pattern. Collaborative: details about the
- Demonstrate - Collaborate with severe abdominal - Demonstrate
behaviors and dietician team. pain to be able to behaviours and
lifestyle changes to give an appropriate lifestyle changes to
regain and/or nursing regain and/or
maintain intervention. maintain
appropriate weight. appropriate weight.
THE GOAL MET!
Dependent:
- To relieve the
severe stomach
pain.

Collaborative:
- To set nutritional
goals when client
has specific dietary
needs, malnutrition
is profound, or
long-term feeding
problems exist.