DAVAO DOCTORS COLLEGE

General Malvar St., Davao City

Nursing Program

AFINIDAD, JIEZL A
Name of Patient: Patient JN Date of Admission: Feb 7, 2021 Room: 401a
Age: 55 years old Chief Complaint: one-month history of episodes of mid-epigastric pain, a “burning”
sensation in his chest, an associated dry cough, and occasional
regurgitation
Religion: Attending Physician: Dr. Sabido

DATE ASSESSMENT NURSING GOALS & NURSING RATIONALE EVALUATION

TIME DIAGNOSIS OBJECTIVES INTERVENTIONS
Feb. Subjective Imbalanced After 3 days of Independent: After 3 days of
11, Cues: Nutrition: Less nursing 1. Accurately 1. For nursing
measure the baseline interventions:
2021 “Tungod aning Than Body interventions: patient’s weight data. patient was be
sige sakit sa Requirements patient will be able and height. 2. Determining able to:
8 AM akong tiyan ug related to to: 2. Obtain a the feeding
suka, wala na ko inability to nutritional habits of the a. ingest daily
gakaon kayo intake enough a. ingest daily history. client can nutritional
3. Encourage provide a requirement
karon” as food as nutritional small frequent basis for s in
verbalized by the evidenced by requirements meals. establishing accordance
patient. weight loss, in 4. Instruct to a nutritional to his activity
nausea and accordance remain in plan. level and
vomiting, to his activity upright position 3. Small and metabolic
at least 2 hours frequent needs.
Objective Cues: pyrosis and level and after meals; meals are b. demonstrate
 Current mid-epigastric metabolic avoiding eating easier to behaviors
weight: 92 pain after needs. 3 hours before digest. and lifestyle
kgs eating. b. demonstrate bedtime. 4. Helps changes to
5. Instruct patient control regain and
 Previous behaviors
to eat slowly reflux and maintain
weight: 86 and lifestyle and masticate causes less appropriate
kgs changes to foods well. irritation weight.
 weight SCIENTIFIC regain and 6. Remind patient from reflux c. be free of
to eat a low-fat action into signs of
 loss BASIS: maintain diet; avoid esophagus. malnutrition.
 mid- appropriate caffeine,
Gastroesophag tobacco, beer, 5. Helps GOAL MET.
epigastric weight.
eal reflux milk, foods prevent
pain after c. be free of containing reflux.
disease
eating signs of peppermint or
(GERD) is a
 inadequat fairly common malnutrition. spearmint, and 6. Caffeinated
e food disorder carbonated foods and
marked by beverages drinks (such
intake 7. Avoid eating or as coffee,
 abdominal backflow of
gastric or drinking 2 tea, colas,
discomfort duodenal hours before and
 nausea contents into bedtime. chocolate)
and the esophagus 8. Instruct to can
that causes avoid wearing aggravate
vomiting tight pants, heartburn
 regurgitati troublesome
symptoms belts, and
on and/or mucosal shapewear, gastroesop
 pyrosis injury to the and hageal
esophagus. constraining clo reflux
GERD can thing that puts disease
cause more pressure on (GERD).
severe abdomen. 7. Avoid
symptoms, like eating
difficult or meals two
painful hours befor
swallowing, e
bleeding in the Dependent: bedtime to
stomach and  Administer reduce
intestines, medication as stomach
anemia and prescribed by acid and
unintentional the doctor. allow the
weight loss due stomach to
to a loss of a. Metoclopra partially
appetite or mide empty its
avoiding food. 10mg/amp contents bef
1 amp IVTT ore sleeping
STAT then .
REFERENCE: 1 amp IVTT 8. Tight-fitting 
Hinkle, J. L., & PRN for clothing put
Cheever, K. H. active s pressure
vomiting. on the
(2018).
abdomen
Brunner & Collaborative: and may
Suddarth’s force acid
textbook of  Refer to and food in
medical- dietitian or your
weight stomach up
surgical management into your
nursing (14th programs, as esophagus.
ed.). Wolters indicated.
Kluwer.

a. To relieve
symptoms
such as
nausea,
vomiting, he
artburn, a
feeling of
fullness
after meals,
and loss of
appetite.

 Can provide
 additional
counseling
and
Focus Data Action Response
assistance
withPatient was able to report
Acute pain  verbalization of Independent:
meeting
relieved pain.
pain (7 to 8
1. Carefully assess pain location and discern individual
pain scale)
pain from GERD and angina pectoris. dietary Goal met
 low-grade fever
needs.
 pyrosis
 regurgitation of 2. Identify factors that causes increase of pain
acid
 abdominal pain 3. Provide information on proper positioning to
prevent gastric reflux.

4. Instruct patient to avoid foods and activity

that may trigger pain caused by gastric
reflux.
5. Avoid strenuous activity and bending at waist
after meals

6. Avoid wearing tight pants, belts, shapewear,

and constraining clothing that puts pressure
on abdomen

Dependent:
1. Administer pain reliever medication as
ordered.