Name of Student: Francine Marie M.

Jamelo Year & Section: BSN-N21 Clinical Area: Murcia Dates of Training: March 24-25, 2023

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:  Imbalance  After 48 hours Independent  Client
 “Ga-sakit akon nutrition less of nursing  Assess the - To provide interventions nutritional
dughan kag gna than body interventions the Nutritional Status according to client’s status improved
palanugnawan requirement patient will and Nutritional needs. as evidenced by
ko.” related to ingest daily needs of the client. tolerance to
 “Waay ko delayed nutritional  Advice the patient to -To relieve Esophageal oral foods,
nanyapon, kag Gastric requirements in take soft solid bland Irritation and improve absence of Acid
palakaon ko Emptying accordance to diet and Avoid hot, Gastric Emptying. reflux.
kahang.” leading to his activity level Spicy and fatty
reflux of and metabolic foods.
Objective: Gastric needs. Patient’s  Advice the client to -To prevent decreasing
 Pain Scale of 8 contents into Pain Scale avoid caffeine, the pressure in the lower
over 10 the esophagus would lower to chocolate and Esophageal Sphincter
 Facial Grimace as evidenced 4 over 10. carbonated drinks. thereby reduces Gastric
Noted by Angina Reflux.
 Vital Signs Pectoris.  Advice the client to -Alcoholism and smoking
Blood Pressure: avoid alcoholism leads to Incompetent
120/90 and smoking Lower Esophageal
Respiratory Rate: Sphincter and further
28 CPM contribute to reflux
Heart Rate: 89 BPM  Advise the client to disease.
Oxygen Saturation: take small and -To neutralize the acid
92% frequent feed and secretion and prevents
remain in upright regurgitation and over
position at least for distention of the stomach.
2 hrs after eating.
Collaborative
 Administer H2
Receptor Antagonist -To decrease HCL
like Ranitidine, Secretion thereby
cimetidine and decreasing the Acid
Anatcids like reflux into the Esophagus.
famotidine proton
pump inhibitors,
like omeparazole as
prescribed.
.