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    Zyra Ambagan
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    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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    Nursing care plan

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    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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    80 views2 pages

    Nursing Care Plan

    Uploaded by

    Zyra Ambagan
    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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    of 2

    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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