Daily Nursing Care Plan

Name of patient: Geneper T. Orquiza age: 69 date admitted: 2/14/2024

Medical diagnosis: Gastropathy
Daily nursing care plan Charting
Date/time Focus Nurse’s notes (FDAR)
Assessment 2/16/2024 Impaired Comfort F – Impaired Comfort
1. Subjective data: 7:30 AM D – Received on bed with 1L PNSS, NH, on right arm
“Hapdos akoang kuto-kuto pero di na kaayo, nagka-alibyo na”, as regulated @ 20gtts/min.
verbalized by pt.  “Hapdos akong kuto-kuto pero di na kaayo,
(+) Body Malaise nagka-alibyo na”, as verbalized by pt.
Pain Scale: 5/10  (+) Body Malaise
A– V/S taken and recorded
 Demonstrated non-pharmacological pain relief
2. Objective data: measure such as distraction techniques to pt.
BP: 120/70 mmHg  Repositioned for comfort and pain relief
Pulse Rate: 70 bpm  Ensured proper hydration by encouraging
Respiratory Rate: 21 cpm additional OFI
O2 Saturation: 96%  Provided health education to the patient and
Temperature: 35.8*C family about gastropathy, its causes, and potential
PNSS 1L NH @ 20gtts/min exacerbating factors
 Instructed pt on the importance of adhering to
Nursing diagnosis/focus: prescribed medications, dietary restrictions, and
lifestyle modifications
Impaired Comfort
 Administered prescribed medications such as
Outcome criterion: proton-pump inhibitors to ensure relief
By the end of my 8 – hours shift, my patient will be eased from her  Maintained intravenous fluids as prescribed to
discomfort maintain hydration and correct any electrolyte
imbalances
Interventions/actions  Facilitated and support the patient through
1. Independent medical procedures or interventions ordered by
 Assess the nature and intensity of the pain. the physician
 Administer prescribed pain medications as appropriate and monitor  Communicated with the healthcare team to ensure
their effectiveness. collaboration
 Implement non-pharmacological pain relief measures such as guided  Collaborated with the dietitian to develop a
 imagery, distraction techniques, or relaxation exercises. suitable diet plan
 Promote proper positioning for comfort and pain relief.  Encouraged to verbalize concerns to the
 Ensure proper hydration by encouraging the patient to drink fluids in healthcare team
accordance with their medical condition.  Monitored for any unusuality
 Monitor and address any signs of dehydration or malnutrition. R – Patient was relieved from discomfort
 Provide education to the patient and family about gastropathy, its
causes, and potential exacerbating factors.
 Instruct on the importance of adhering to prescribed medications,
dietary restrictions, and lifestyle modifications.
 Teach relaxation techniques or breathing exercises to help manage
stress and discomfort.
2. Dependent
 Administer prescribed medications such as proton-pump inhibitors.
 Administer intravenous fluids as prescribed to maintain hydration and
correct any electrolyte imbalances.
 Facilitate and support the patient through medical procedures or
interventions ordered by the physician
3. Collaborative
 Communicate effectively with physicians, nurses, and other
healthcare team members to discuss the patient's response to
interventions and adjust the plan of care as needed.
 Collaborate with the dietitian to develop a suitable diet plan that meets
the patient's nutritional needs while taking into consideration the
gastropathy.

Name of student: Paul Andre V. Aggabao, MUSN CI: Ms. Andrea S. Almeda, RN Signature and date: 2/17/2024