Assessment Diagnosis Objective Intervention Rationale Evaluation

Nursing History: Knowledge deficit After an hour of Independent: After an hour of

r/t condition nurse-patient 1. Provides knowledge base from nurse-patient
A case of Ms. J.M, 16 year prognosis, treatment, interaction the 1. Review disease which patient can make interaction the
old, complained of self care and risk patient will process/prognosis. Discuss informed choices. Effective patient was able to
persistent severe factors for peptic verbalize hospitalization and communication and support at verbalize
abdominal pain. ulcer. understanding of prospective treatment as this time can diminish anxiety understanding of
disease indicated. and promote healing. disease
process, prognosis, Encourage questions, process, prognosis,
Subj. cue: and potential expression of concern. 2. Changing position worsens the and potential
complications. 2. Teach the patient to change pain, so the person often tries to complications.
“ mubalik pa kha ni ako positions slowly
lie very still.
sakit? As verbalized by 3. Teach the patient about the
3. Bland diets may help reduce
patient. appropriate foods to eat when
acid, Restrict or avoid those
nauseated and those to avoid
foods that may cause irritation
4. Teach the patient the
to the digestive system.
Obj. cue: importance of maintaining
4. The body, for its well-being and
fluid intake
to enable it performs mentally
 Frequently asking 5. Teach the patient that they
and physically, requires a
question about his need to contact the doctor if
balanced fluid intake.
condition, vomiting persists for more
5. Even if your symptoms are mild,
treatment and diet than 24 hours
you may have peptic ulcers. You
 With worried gaze should see your doctor to talk
about your symptoms. Peptic
Lab: ulcers can get worse if they
None aren’t treated.

NURSING CARE PLAN

Name of Pt. ________MS. J.M_______________ Date: _______________________