ACUTE CORONARY SYNDROME STEMI NURSING CARE PLAN PDF

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Summary

Guide for student nurses in establishing nursing care plans, health teaching plans using METHOD, and drug study assignments...

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Henriette Jane De Leon

BN3A

January 21, 2021

Nursing Care Plan Patient’s Name: RV Assessmen t Cues Subjective Cues: Patient complaine d of being nauseous "daw kasukahon ko miss kada mag kaon"; Patient still felt pain in the abdominal area.

Age: 33 y/o

Sex: Male Diagnosis: GERD (Gastroesophageal Reflux Disease)

Pathophysiologic/ Nursing Diagnosis

Desired Outcome Schematic Diagram

Imbalanced nutrition: less than body requirements r/t inadequate nutritional intake aeb anorexia

Predisposing Factors:  

Age Sex

After 8 hours of Nursing Intervention, the patient and significant other will be able to:

Precipitating Factors:

Definition: Intake of nutrients insufficient to meet metabolic needs

Objective Cues:

Source:

Pain scale:

http://nursingcarepla

 



Unbalanced Diet Physiological problem in the connective tissues of GI Medications such as for asthma

 Intake of Food rich in caffeine, fats, acidic etc., and medications (ex. For asthma anticholinergics)

1. Demonstrate increased nutritional intake according to his specified diet.

2. Verbalized understandin g of causative

Nursing Intervention Independent Interventions: 1. Assess the contributin g factor of inadequate nutritional intake and taking vital signs. 2. Encourage client to follow the prescribed diet ordered by the physician such as low fat, low salt, no caffeine,

Rationale Independent Interventions: 1. This will help the nurse to perform initial measures to provide an action in promoting adequate nutritional intake. Problems found in initial data can be reported back to colleague and physician. 2. Caffeine, spicy food, fats, and salty foods can trigger or

Evaluation After 8 hours of Nursing Intervention, the patient and significant other was able to:

1. Demonstrate increased nutritional intake by choosing his own preference of food according to the recommende d diet. GOAL MET 2. Understand the nature of

Henriette Jane De Leon

n-s.blogspot.com /2012/08/nursingVital signs: care-plan-forT: 37 C imbalancednutrition-lessPR: 86 than-bodybpm requirements RR: .html?m=1 18cpm 5/10

BP: 120/70 mmHg

BN3A

 Abnormal Lower Esophageal Sphincter relaxation  Excessive/prolonge d Transient LES Relaxation  HCl in stomach is pushed by intraabdominal pressure or positional change (lying down)

s/s Heartburn Chest pain Sensation of lump in throat Chronic Cough Laryngitis Regurgitation of food or sour liquid Difficulty in Swallowing

factors when known and necessary interventions . 3. Display behaviors, lifestyle, changes to regain and/or maintain appropriate weight.

January 21, 2021

and avoid spicy foods. 3. Promote hygiene such as oral hygiene. 4. Assist client in a comfortabl e position such as the semifowler’s. In addition, advice client the appropriate sleeping position which is on his left-side and do not lie down immediatel y after

worsen the symptoms of GERD. Fatty foods can cause the LES to relax; Acidic foods can increase the production of acid. 3. The HCl acid that backs up into your esophagus can cause complications in the upper part of the GI such as the throat and mouth. To avoid infection, oral hygiene should be done to eliminate bad breath and microorganism s that may

the patient’s condition. He was able to grasp the necessary interventions such as positioning, proper diet, and what to avoid to prevent GERD in the future. Patient verbalized “Sige ms, thank you gid. Tandaan ko gid na ms tanan” GOAL MET 3. Identify the measures needed to be changed in his lifestyle such as his diet. GOAL

Henriette Jane De Leon

BN3A

GERD (Gastroeophageal Reflux Disease)

Imbalanced nutrition: less than body requirements r/t inadequate nutritional intake aeb anorexia

January 21, 2021

eating.

Dependent Interventions: 1. Give medication s as per physician’s order. 2. Inform physician of the patient’s complain regarding nausea after eating.

cause infection. 4. Lying down can cause gastric acid to leak out with a weaken Lower Esophageal Sphincter. Hence it will be more painful for the chest area and the abdomen. Elevating the head such as in the semifowler’s position will retain the gastric acid in the stomach. Sleeping on left-side will reduce reflux. The stomach is positioned below your esophagus,

MET

Henriette Jane De Leon

BN3A

January 21, 2021

which makes reflux more difficult. Dependent Interventions: 1. Proton pump inhibitors are common drugs used for GERD to reduce stomach acid. 2. Medication for nausea can be ordered by physician if informed....