ASSESSMENT NURSING BACKGROUND PLANNING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS KNOWLEDGE
Acute pain Risk factors Within 1 week of Independent: After 1 week of nursing
related to nursing 1. Established rapport 1. To gain the trust intervention, the client
Subjective: irritation in Gastric irritation intervention the with patient and family of the patient. was able to experience
“Masakit ang tiyan mucosa and client will be relief in symptoms,
ko, ilang araw na abdominal Increased gastric able to maintain nutritional
muscle spasm as 2. Assessed the 2. To determine the
may kasama na secretion experience relief balance and recognize
evidenced by characteristics of the exact location of
in symptoms, the contributing factors
ding pagsusuka ng abdominal pain client’s pain. the client’s pain
Hyperacidity maintain but is having a hard time
dugo” as with pain scale which usually
nutritional in lifestyle changes.
verbalized by the of 8/10, nausea Damage of the mucosa balance and happen after
patient. and vomiting recognize the eating. GOAL WAS
with food and
Ulceration formation contributing 3. Monitored and record 3. To note for any PARTIALLY MET.
Objective: blood.
factors together the vital signs and abnormalities and
 V/S: GI bleeding with lifestyle compare it to baseline. carry out
Temp: 37.8 changes. interventions
PR:75 bpm Abdominal pain with
RR:22 cpm before
hematemesis
O2 Sat: 96% complications
BP: 100/70 arise.
mmHg
4. Monitored fluid intake 4. To check for
 Burning
abdominal and output possible
pain with dehydration
pain scale of 5. Checked for possible 5. To carry out
8/10
GI bleeding or interventions and
 Nausea and
vomiting perforation prevent possible
 Hematemesi complications
s
6. Monitored the lab 6. To check for any
results of the patient abnormalities like
( CBC, electrolytes, anemia
Hbc)
7. Explained to the client 7. To carry out
about his condition : possibilities for
signs and symptoms, lifestyle changes
causes and like smoking and
interventions drinking cessation
providing needed
 information
8. Allowed the client to 8. Decrease the
use some non- release of gastric
pharmacological reliefs acid and thus
(music therapy, guided reducing pain
imagery and careful
massage)

9. Instructed the client to 9. These

avoid NSAIDs medications can
cause irritation in
mucosa.
Dependent: Dependent:

1. Administered 1. To manage the

medications ordered by symptoms of the
the physician : client
 Sucralfate 1 gram in 20
ml water QID 1 hour
before meals and at
bedtime
 Omeprazole 40 mg
TIV every 12 hours
 Metronidazole
500mg/100ml 1 bottle
TIV every 8 hours
 Clarithromycin 500 mg
powdered diluted to
distilled water TIV
every 12 hours
 Tramadol (Tramal)
50mg/ml TIV PRN
 Plasil 5mg/ml PRN

2. Provided IVF D5NR 2. To avoid

1L X 12 hours and complications
D5NM 1L X 12 hours such as
alternatvely dehydration
 Collaborative: Collaborative:

1. Collaborated with a 1. To maintain the

nutritionist to provide
adequate nutrition
necessary diet and
avoid irritating food of the client.
and beverage such as
coffee.

ASSESSMENT NURSING BACKGROUND PLANNING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS KNOWLEDGE
Risk for fluid Risk factors Within 48 hours Independent: Independent: After 48 hours of
volume deficit of nursing 1. Established rapport 1. To gain the trust nursing intervention,
Subjective: related to food Gastric irritation intervention, the with the client. of the patient. the client will be
“Sinusuka ko lang and blood loos client will be able to manifest
2. To check for
ang mga kinakain secondary to Increased gastric able to manifest 2. Monitored the client’s adequate fluid
peptic ulcer possible fluid
ko at may secretion adequate fluid intake and output balance and acquire
disease as deficiency
balance and nutritional needs.
kasamang dugo” as evidenced by 3. To note for any
Hyperacidity acquire 3. Monitored the client’s
verbalized by the burning vital signs abnormalities and
nutritional needs. GOAL WAS MET
patient. abdominal pain Damage of the mucosa carry out
with pain scale interventions
Objective: of 8/10, nausea
Ulceration formation before
 V/S: and vomiting of
food and blood. complications
Temp: 37.8 GI bleeding arise.
PR:75 bpm
RR:22 cpm 4. Monitored the client’s 4. To provide for
Abdominal pain with
O2 Sat: 96% hematemesis and needed
BP: 100/70 hematemesis
melena interventions
mmHg
 Burning 5. Instructed the client to
abdominal 5. To provide
report any symptoms
pain with needed
like nausea, vomiting,
pain scale of interventions for
8/10 dizziness and shortness
of breath GI bleeding.
 Nausea and
vomiting 6. Monitored the lab 6. To know
 Hematemesi results of the client abnormalities and
s (CBC) provide needed
interventions
7. To know when
7. Monitored GI bleeding and what
or perforation intervention to
give and avoid
complications
Dependent:
Dependent: 8. To manage the
1. Administered symptoms of the
medications ordered by client
the physician :
 Sucralfate 1 gram in 20
ml water QID 1 hour
before meals and at
bedtime
 Omeprazole 40 mg
TIV every 12 hours
 Metronidazole
500mg/100ml 1 bottle
TIV every 8 hours
 Clarithromycin 500 mg
powdered diluted to
distilled water TIV
every 12 hours
 Tramadol (Tramal)
50mg/ml TIV PRN
 Plasil 5mg/ml PRN

2. Provided IVF D5NR 2. To avoid

1L X 12 hours and complications
D5NM 1L X 12 hours such as
alternatvely
dehydration
3. Administer blood
3. To maintain
transfusion of PRBC 4
normal blood
units of blood after
level
properly checked and
cross matched.