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Nursing Care Plan

1) The patient presented with abdominal pain, bloody stool, and a history of ulcers. Initial vital signs showed an 8/10 pain level. 2) The nursing diagnosis was acute pain related to gastric acid secretion damaging tissues. Short term goals were to reduce pain to 2-4/10 within 30 minutes and demonstrate relaxed posture. 3) Interventions included avoiding acidic foods, eating regularly, encouraging rest, and pain medication. Long term goals were baseline vital signs and absence of complications within 2-4 hours.

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Zyra Ambagan
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234 views2 pages

Nursing Care Plan

1) The patient presented with abdominal pain, bloody stool, and a history of ulcers. Initial vital signs showed an 8/10 pain level. 2) The nursing diagnosis was acute pain related to gastric acid secretion damaging tissues. Short term goals were to reduce pain to 2-4/10 within 30 minutes and demonstrate relaxed posture. 3) Interventions included avoiding acidic foods, eating regularly, encouraging rest, and pain medication. Long term goals were baseline vital signs and absence of complications within 2-4 hours.

Uploaded by

Zyra Ambagan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Antenor, Nheil Jhustine

BSN 2 – A (Group 1)
NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective Data: Acute pain related to the Short Term: Independent: After the nursing
“Sumasakit po ang sikmura effect of gastric acid After 30 minutes of nursing - Avoid foods and interventions, the patient;
ko” secretion on damaged interventions, the patient will beverages that - Demonstrated
“Dumudura po ako ng dugo” tissue. be able to; contain acid- relaxed body
“Meron po akong ulcer” - The client will report enhancing caffeine posture.
satisfactory pain (colas, tea, coffee, - Gained knowledge
Objective Data: control at a pain chocolate), along about the
management and
- facial expression of level of less than 2 with decaffeinated
prevention of ulcer
pain to 4 on a scale of 0 coffee. recurrence.
- Abdominal Guarding to 10. - Encourage patient to - Verbalized relief pf

- Demonstrate eat regularly spaced pain in the

Initial Vital Signs: relaxed body meals in a relaxed abdominal area.

Pain scale: 8/10 posture and able to atmosphere; obtain


rest appropriately regular weights and Latest Vital Signs:

- Have knowledge encourage dietary Pain scale: 3/10

about the modifications.


management and - Encourage rest and
prevention of ulcer position the patient
recurrence. in a comfortable
position.
Long Term: - Assess the pain
After 2 – 4 hours of nursing scale.
interventions, the patient will - Educate the patient
be able to; on relaxation
- The client will exhibit techniques.
increased comfort
such as baseline Dependent:
levels for HR, BP, - Administer
and respirations, prescribed
and relaxed muscle medications.
tone for body
posture.
- Show absence of
complications.

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