Signs and Symptoms

Palmar pallor
Easy fatigability
Weakness
Restlessness

Nursing Diagnosis

Rationale

Objective

Nursing Intervention

Rationale

Evaluation

Risk for decreased

The patient had a
Short term
massive amount of
After 7 hours of
Monitor bloodpressure
Bounding
After 7 hours of
cardiac output
nursing intervention:
periodically.Measure
carotid, jugular,
nursing intervention:
related to increased blood loss in relation
to peptic ulcer disease
The patient
both armsthree times; radial,femoral pulses The patient maintained
vascular
which
predisposes
the
willmaintain
3-5 minsapart while
may beobserved/
bloodpressure
vasoconstriction
patient in to decreased
bloodpressure
patient isat rest for
palpated.Pulses in the
withinacceptable
cardiac output and
withinacceptable
initialevaluation.2.
leg maybe
After 3 days of nursing
also since patient
Long Term
Note presence
diminished,implicating
intervention
develop hypertension After 3 days of nursing
of,quality of central
effects
The patient
in later life, their
intervention
andperipheral pulses.
of vasoconstriction
demonstrated
cardiac output falls
The patient
Auscultate heart
andvenous
stablecardiac rhythm
and peripheral
willdemonstrate
tonesand breath
congestion.
and
resistance rises with
stablecardiac rhythm
sounds4.
S3 and S4
rate within patients
and
Observe skin
heartsounds may
normal range
age.
rate within patients
color,moisture,
indicateatrial and
normal range
temperatureand
venoushypertrophy
capillary refilltime
andimpaired
Note independent
functioning
orgeneral edema
Presence
Provide a
of adventitious
calmenvironment;mini
breathsounds may
mizing noise;limiting
indicatepulmonary
visitors andlength of
congestionsecondary
stay.
todeveloping
heartfailure
Presence of pallor;cool
and moist skinand
delayed capillaryrefill
may be due
toperipheralvasoconstr
iction ordecreased
cardiacoutput.
It may indicate
heartfailure, vascular
orrenal impairment.6.
Promotes relaxation.

Signs and
Symptoms
Malaise
Great need for
sleep and rest
Verbalized
nanghihina
ako
History of
peptic ulcer
disease (PUD)
bleeding
Palmar pallor

Nursing
Diagnosis
Anemia due
to bleeding
related to
duodenal
ulcers.

Rationale

Objective

Nursing
Intervention

Anemia is a
Short Term
condition in
After 7 hours
Assess patients
which blood
of nursing
ability to perform
has a lower
interventions
normal task or
than normal the patient will: activities of daily
number of red
Report an
living.
blood cells.
increase in
Note changes in
Anemia also
activity
balance/ gait
can occur
tolerance
disturbance,
when red
including
muscle weakness.
blood cells
activities
Recommend quiet
dont contain
of daily living.
atmosphere, bed
enough
Long term:
rest if indicated.
hemoglobin.
After days
Elevate the head
The patient
of nursing
of the bed as
had a massive interventions,
tolerated.
amount of
the patient:
Provide or recommend
blood loss in
Is free from
assistance with
relation to
weakness and
activities or
peptic ulcer
risk for
ambulation as
disease and
complications necessary, allowing
laboratory
has been
patient to do as
results
prevented.
much as possible.
presented
Evaluate
signigicant in
medication such as
HbG count.
NSAID,
anticoagulant,
corticosteroids,
ginko biloba

Rationale

Evaluation

Influences choice
of interventions or
needed assistance.
May indicate
neurological changes
associated with
vitamin B12deficiency,
affecting patient safety
or risk of injury.
Enhances rest to
lower bodys oxygen
requirements, and
reduces strain on the
heart and lungs.
Enhances lung
expansion to
maximize oxygenation
for cellular uptake.
Although help maybe
necessary, self esteem
is enhanced when
patient does some
things for self.
These drugs
predispose client to
PUD

Patient reveals an
increase in activity
tolerance,
demonstrating a
reduction in
physiological
signs of intolerance
and laboratory values
within normal range.

Signs and
Symptoms

Nursing
Rationale
Diagnosis
Acute Pain
Some individuals produce
Facial
due to the excessive quantities of acid,
grimace
effect of
and this leads to
Was
gastric acid development of a duodenal
observed to secretion on ulcer. This type of response
have
damaged
occurs when gastritis is
guarding
tissue
localized in the pyloric
behavior of secondary to
region. The cytokines
the
NSAID
released in response to
abdomen
medication
inflammation disrupt the
pain scale of
regulation of the endocrine
5/10
cells located in the pylorus.G
cells are stimulated to
secrete more gastrin,
while somatostatin secretion
is inhibited. Gastrin
stimulates parietal cell
proliferation and increased
parietal cells along with
decreased somatostatin
leads to acid hypersecretion.
The acid-neutralizing
mechanisms (pancreatic and
duodenal bicarbonate
secretion) become
overwhelmed, and the
duodenal tissue becomes
damaged.

Objective
Short Term
After 7
hours of
nursing
intervention
patient will:
Be able to
express
relief or pain
has been
diminished.
Long Term
After 3 days
of nursing
intervention
patient will:
No longer
feel any
pain and the
ulcers are
managed
completely

Nursing Intervention Rationale

Avoid aspirin,
which is an
anticoagulant, and
foods
and beverages
that contain acid
enhancing
caffeine (colas,
tea, coffee,
chocolate), along
with decaffeinated
coffee.
Encourage patient
to eat regularly
spaced meals in
a relaxed
atmosphere;
obtain regular
weights and
encourage dietary
modications.
Encourage
relaxation
techniques like
breathing
exercises.

To prevent
further
secretion
and
irritation of
gastric
mucosa
from acid.
In order for
food to
neutralize
the acidity
of the
secretions
prevent the
secretions
from
causing
more
damage to
ulcers.
To facilitate
calmness
and reduce
stress and
provide
comfort.

Evaluation

After 7
hours of
nursing
intervention
patient was:
Able to
express
diminished
pain and
pain scale
went to 2/10
from 5/10
After 3 days
of nursing
intervention
patient was:
No longer
feeling
abdominal
pain.

Signs and
Nursing Diagnosis
Symptoms
di ako makatulog
Sleep deprivation
ng maayos.
due to anxiety
paano ba madaling related to outcome
makatulog?
of disease condition.
Observed as
restless and irritable
nahihirapan ako
kasi may mga anak
akong pinag-aaral.
binenta ko na nga
yung tricycle namin
eh.

Rationale

Objective

This problem is
common during
hospitalizations. The
patients are always
subjected to some
procedures, such as
VS monitoring,
laboratory measures
and also checking
the patency of the
IV fluid. With these
actions, it is
therefore related for
having sleep
deprivation. Also,
excessive thinking
and dwelling on the
"what ifs"
characterizes this
anxiety disorder. As
a result, the person
feels theres no way
out of the vicious
cycle of anxiety and
worry, and becomes
depressed about life
and the chronic
state of anxiety they
find themselves in

Short Term
After 7 hours of
nursing intervention,
the client will be
able to:
Have an adequate
sleep and will
experience a
refreshed sleep
continuously.
.
Long Term
After days of nursing
intervention:
The client will take
an eight-hour sleep
each day as well as
nap or rest period

Nursing
Intervention
Recommend
positions for sleep
that provide
adequate support.
Recommend a nap
or rest period each
day.
Discourage
entertaining or
frequent visits from
others
Environment
modification and
limit activities before
sleep.
Encourage free
expressions of
feelings, including
feelings of anger
and hostility
Listen to clients
concerns and
acknowledge
difficulty of adversity
and making
changes in situation.
Provide information
at clients level of
comprehension,
being honest in
explanations

Rationale

Evaluation

Sleep is needed to
feel refreshed
The client
and restored.
experienced a
Proper support
refreshed sleep
with pillows for the
continuously
sideThe client took an
lying position promot eight-hour sleep
es relaxation
each day as well as
and aids sleep.
nap or rest period
Visiting with friends
uses energy
and contributes
to fatigue
To prepare body for
sleeping and have a
cooldown state
before going to bed
and sleep.
To express anger
and control the
behavior and
prevent feelings of
shame and guilt.
Being listened to
provides opportunity
for client to feel
valued, capable.
Provides data to
assist in decisionmaking process.

Signs and
Nursing
Rationale
Objective
Symptoms
Diagnosis
Slurred speech
Impaired verbal
The verbal
Short Term:
Hoarseness of
communication
communication
After 7 hours of
voice
related to difficulty may be impaired
nursing
Endotracheal tube
in speaking
by several factors
intervention
inserted
such as tissue patient will be able
Verbalized pain
trauma, cranial
to:
pakiramdam ko
nerve impairment,
Verbalize an
ako si Donald
and brain
understanding of
Duck
damage. This
the
may interrupt the
communication
normal
Long Term:
communication
After days of
with surrounding
nursing
people, and
intervention
activities of daily patient will be able
living related to it.
to:
This may impair
Identify ways to
self-worth, selfimprove
esteem and the
communication
function as a
person. The
patient has a
difficulty in verbal
speech due to the
painful throat,
related to tissue
trauma from
endotracheal tube
insertion.

Nursing
Intervention
Maintain a calm,
unhurried manner.
Provide sufficient
time for client to
respond.
Pay attention to
speaker and be
an active listener
Sit down, maintain
eye contact, stay
with the patient
Observe body
language, eye
movements and
behavioral cues

Rationale

Evaluation

An atmosphere in After 7 hours of

which client is free
nursing
to speak without
intervention
fear of criticism,
patient was able
client can improve
to:
communication
Show signs of
skills.
understanding
The use of active
how to
listening
communicate and
communicates
verbalized an
acceptance and understanding of
respect for the
the
client.
communication
Conveys nurse
After days of
has time and
nursing
interest in
intervention
communicating
patient was able
May reveal
to:
unspoken
Identify different
concerns like pain ways to improve
if patient, tears,
communication
turning away or
like writing or
grimacing.
being able to
speak words
slowly but audible.