Francisco, Krisianne Mae L.

BSN III B (group B3)

Gastroesophageal Disease Nursing Care Plan

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective Acute Pain related to After 6 hours of Independent After 6 hours of nursing
“namamalit na po ako sa irritated esophageal nursing  The head of the bed should be  To relieve heartburn intervention, the client the
sobrang sakit po ng tiyan ko mucosa as evidenced intervention, the placed on 4 to 8 inches blocks. sensation. client reported decreased
at mainit na pakiramdam sa by verbalization of client will report of pain as evidenced by
dibdib ko” pain, cough, relieved of pain.  Advise the client to avoid food or  To minimize occurrence the pain scale from 8/10
heartburn, drink 2 hours before bedtime or of indigestion. into 2/10. Goal met.
Objective dysphagia, and lying down after eating
 sore throat abdominal pain.
 cough  Encourage the patient to avoid  To prevent reflux.
 dysphagia activity and remain upright for 1 to
 abdominal pain with 4 hours after each meal.
pain scale of 8/10
 Heart burn  Advise the patient to avoid tight  To enhance breathing
 Regurgitation fitting clothes. pattern this may
 Mid-thoracic, contribute in relieving
bilateral back pain pain.

Vital signs  Instruct the patient to eat slowly and  To promote proper
 BP: 132/78mmHg chew food thoroughly. digestion of food.
 PR: 80 bpm
 RR: 18 bpm
 BT: 37.3 ⁰C

Dependent
  Administer medication as  For medical
prescribed by the physician and management of acid
monitor the patient regularly. reflux disease to relieve
pain.

Collaborative  In order for the food to

 Discuss with family members to pass easily into the
provide patient small, frequent stomach.
feedings.

 Discuss with the family members  For their awareness to

the effect of irritants such as encourage the patient to
tobacco and alcohol. avoid them because
irritants can worsen the
client’s condition.

 Discuss with the family members to  To minimize the

avoid very hot or cold foods, spices, worsening of patient’s
fats, coffee, chocolates, and citrus condition.
juices.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective Imbalanced After 4 hours of Independent After 6 hours of nursing

“pakiramdam ko po Nutrition: Less Than nursing intervention, the client
nangangayayat na po ako Body Requirements intervention, the  Obtain a nutritional history.  Determining the feeding verbalized change in
kasi hindi po ako related to lack food client will verbalize habits of the client can eating habits as evidenced
nakakakain ng maayos ng intake due to reflux change in eating provide a basis for by eating small, frequent
isang buwan.” as evidenced by habits to meet his establishing a meal; eating slowly and
dysphagia, nutritional needs. nutritional plan. chewing food thoroughly;
Objective abdominal pain, and avoiding irritants.
 sore throat regurgitation, weight  Advise the client to avoid food or  Helps control reflux and Goal met.
 dysphagia loss, postprandial drink 2 hours before bedtime or causes less irritation
 Heart burn fullness and early lying down after eating from reflux action into
 Abdominal pain satiety. esophagus.
 Regurgitation
 increasing  Encourage the patient to avoid  To prevent reflux.
postprandial fullness activity and remain upright for 1 to
 early satiety 4 hours after each meal.
 Weight loss from
190 lbs to 102 lbs.  Advise the patient to avoid tight  To enhance breathing
fitting clothes. pattern this may
Vital signs contribute in relieving
 BP: 132/78mmHg pain.
 PR: 80 bpm
 RR: 18 bpm  Instruct the patient to eat slowly and  To promote proper
 BT: 37.3 ⁰C chew food thoroughly. digestion of food.
 Height: 65 inches
 Weight: 102 lbs
 Weigh the patient daily.  To monitor patient’s
 BMI: 16
nutritional status.
(underweight)
Dependent
 Administer medication as  For medical
prescribed by the physician and management of acid
monitor the patient regularly. reflux disease.

Collaborative
 Discuss with family members to  In order for the food to
provide patient small, frequent pass easily into the
feedings. stomach.

 Discuss with the family members  For their awareness to

the effect of irritants such as encourage the patient to
tobacco and alcohol. avoid them because
irritants can worsen the
client’s condition.

 Discuss with the family members to  To minimize the

avoid very hot or cold foods, spices, worsening of patient’s
fats, coffee, chocolates, and citrus condition.
juices.