NURSING CARE PLAN

Name of Patient: R.V.B. Age: 37 y.o. Sex: Female Civil Status: Married Room/Bed No.: 313
Medical/Surgical Diagnosis: Erosive Gastritis, SLE in flare with SLE-DAS 12, Hiatal Hernia Admission Date: September 12, 2 Shift: 6am –2pm
Prepared by: Ceegi Arville C. Roldan Section/Grp No.: BSN 403 – Group 4 CI/Supervisor: Mrs. Concepcion Deciembre
Cues Nursing Analysis Goals and Objective Implementation Rationale Evaluation
Diagnosis

SCIENTIFIC Short-term Goal

Impaired Comfort related ANALYSIS:
Subjective Cues: to physical and emotional After a 1 and half hour
distress secondary to erosive According to the sequence of nursing
gastritis as evidenced by definition of NANDA, interventions, the patient
- The client verbalized,
pain, fatigue, and mental Impaired Comfort is the will be able to verbalize a
“minsan napapaluha
exhaustion. apparent lack of comfort, pain score less than 3 and
nalang ako kapag demonstrate how to employ
relief, and illumination of
sobrang sakit na ng an individual’s methods of coping in
tiyan ko. Nahihirapan physiological, psycho- stressful situations .
ako mag relax tulad ng spiritual, environmental,
sinabi ng anak at asawa intellectual, and social
ko.” patterns. Long-term use of
pharmaceuticals known as Objectives:
Objective Cues: non-steroidal anti-
inflammatory drugs is the Cognitive:
● Endoscopy: Erosion most frequent cause of
Noted erosive gastritis. Independent Intervention:
● Urinary Bladder:
Moderately Distended Erosive Gastritis is an MET. The client was able
● Collon: Filled with fecal ulcer-like stomach 1. The client will ● Teach client of the - Almost all of the to demonstrate non-
inflammation that is identify medications for pharmacological pain
materials different medications
characterized by numerous medications gastritis are related to management activities and
that prevents stomach
lesions in the mucous allowed and stomach acid. techniques after 1 and half
- Guarding of stomach membrane. Symptoms may pain in patients with
appropriate for Patients with gastritis hours of nursing
- Presence of anxiety include weakness, a loss of gastritis:
patients with are prescribed to take intervention.
- Distressed facial appetite, a burning and erosive gastritis. - Proton pump
antibiotic
expression heavy feeling in the pit of inhibitors
medications to kill H.
- Restlessness the stomach, mild nausea, (omeprazole pylori; medications
- Cannot sit or walk due and vomiting. (Prilosec), that block acid
to pain lansoprazole production and
SITUATIONAL (Prevacid), promote healing; acid
Measurements: ANALYSIS: rabeprazole blockers to reduce the
The client is a 37 year (Aciphex), production of
Pain Scale: old female, diagnosed with pantoprazole stomach acid; and
- 10/10 erosive gastritis. (Protonix) and antacids to neutralize

Lymphocytes: 0.402 As stated by the client,
he has Diabetes and is
currently taking
maintenance medicines.
Upon assessment, the
client is showing signs of
distress, anxiety, and
restlessness. The patient
was also unable to sit or
walk due to generalized
abdominal pain radiating to
the back. According to the
patient, she is having
difficulty in relaxing
herself which is her coping
mechanism against the pain
caused by gastritis. The
client’s Endoscopy test
results have shown to note
erosion with a moderately
distended urinary bladder
and a colon filled with
fecal materials. Her
lymphocytes was measured
to be 0.402 which indicates
that the body is dealing
with an infection or other
inflammatory condition.
(NANDA
International, 2016)
(NORD, 2007)
(Vakil, 2021)
others)
- Acid
stomach acid. Pain
blockers(histamine relievers or NSAIDS
(H-2) blockers) such as ibuprofen and
- Antacids naproxen sodium can
both cause or worsen
gastritis and chronic
gastritis.
(St. Elizabeth Healthcare,
2022)
- It is important for
Independent intervention: patients to understand MET. The client was able
their condition as to verbalize symptoms to
patients do not fully expect when diagnosed
2. The client will understand their
● Inform the client about with erosive gastritis after
verbalize condition as much as 1 and half hours of nursing
symptoms to the following:
a healthcare provider intervention.
expect when - What symptoms one
does. Lack of
diagnosed with should expect when
apprehension towards
erosive gastritis. diagnosed with one’s diagnosis can
erosive gastritis. lead to an increase of
● Dyspepsia adverse events
● Nausea towards their
● Vomiting recovery and cause of
panic and confusion.
(Yadav, 2019)
 - Nonpharmacologic
pain management are
activities that manage MET. The client was able
Psychomotor: Independent Intervention:
pain without to demonstrate non-
medication. It utilizes pharmacological pain
methods that alter an management activities and
individual’s thoughts techniques after 1 and half
● Teach non- and focus hours of nursing
3. The client will
demonstrate pharmacologic pain concentration. intervention.
different non- management techniques
pharmacologic pain and activities:
- Imagery/ (Stanford Medicine, n.d.)
management
techniques and visualization with
activities. guidance
- Exercising breathing
techniques
- Meditation
- Therapeutic music

\
- Although there is no
specific diet for
gastritis, there are MET. The client was able
Dependent Intervention: to adhere to the prescribed
specific foods that
patients should avoid appropriate meal plan to
and take in order to the patient after 1 and half
alleviate or prevent hours of nursing
● Refer to a registered symptoms of intervention.
4. The client will dietitian for
adhere to the gastritis. As gastritis
individualized diet involves
prescribed instruction.
appropriate meal inflammation of the
plan for patients gastric lining, an anti-
with erosive inflammation diet
Independent Intervention: would benefit
gastritis.
patients with gastritis.
 ● Assist the patient in
identifying eating Fresh fruits,
patterns that need to be vegetables, and other
modified. plant foods that are
rich in antioxidants. It
● Discuss the following to is also important to
the client: avoid processed
- Importance of foods and other foods
modifying diet in the that contain
prevention and unhealthy amounts of
alleviating gastritis sodium, sugars, and
symptoms; fats.
specifically stomach
pain. (Sethi, 2020)

- The patient's health-

related result has MET. The client was able
been shown to be to express concerns about
influenced by nurse- her condition after 1 and
Independent Intervention:
patient interactions. half hours of nursing
Affective: Showing empathy, intervention.
creating trust,
advocating for the
● Provide a safe
patient, offering
environment for the client
5. The client will informative feedback,
to openly express
express concerns and responding to the
concerns about her
about his condition. patient's unmet needs
condition.
are all examples of
● Attend to the client’s MET. The client was able
excellent therapeutic
questions and concerns to participate and cooperate
interactions. This
regarding her condition with the nursing
form of professional
interventions provided
interaction can help after 1 and half hours of
patients feel more nursing intervention.
satisfied.
 Independent Intervention: (Bennett, 2020)

6. The client will be ● Encourage the client to

able to participate participate during the
and cooperate with performance of nursing
the nursing interventions.
interventions ● Maintain nurse-client
provided. relationship

References:
- Management of Pain without Medication. (n.d.). Stanford Medicines. Retrieved October 7. 2022 from https://stanfordhealthcare.org/medical-conditions/pain/pain/treatments/non-pharmacological-pain-
management.html
- Yadav, A. K. (2019). Patients Understanding of their Diagnosis and Treatment Plans During Discharge in Emergency Ward in a Tertiary Care Centre: A Qualitative Study. National Library of Medicine.
Retrieved October 7, 2022 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7580442/
- Vakil, N. (2021). Erosive Gastritis. MSD Manual. Retrieved October 7, 2022 from https://www.msdmanuals.com/professional/gastrointestinal-disorders/gastritis-and-peptic-ulcer-disease/erosive-gastritis