INCP #1 - CARE PLAN PDF

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CARE PLAN...

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Individualized Nursing Care Plan (INCP) Student Name: Robert Mendel Patient Identifier: RM Date: 10/9/20 Patient Medical Diagnosis: GERD Nursing Diagnosis: Acute pain r/t irritation if esophagus from gastric acids AEB chest pain after meals and burning sensation behind chest Page in NANDA: 147, 640, 871 Assessment Data

1. Pt has difficulty swallowing

2. Pt reports burning sensation behind chest

3. Pt reports chest pain 6/10 after meals

4. Pt has regurgitation of food

5. Burning sensation is exacerbated with changes in pt position

Reviewed & Revised 9/2020 by NCook

Goals / Outcome “Patient will…”

Nursing Interventions “Nurse will…”

(Rationale)

Outcome Evaluation & Replanning

Patient will report chest pain of < 3/10 after ⅔ of meals during the shift.

1. Nurse will explain to the patient the pain management approach, including pharmacological and nonpharmacological interventions.

1. “One of the most important steps toward improved control of pain is a better understanding of the nature of pain, its treatment, and the role the patient needs to play in pain control” (Ackley et al., 2017, p.641).

1. Goal met. Patient’s pain < 3/10 after ⅔ of meals with effective communication on pain schedule. Will continue the current plan of care.

2. Nurse will teach and implement nonpharmacological interventions when pain is relatively well controlled. 3. Nurse will ask patient to describe prior experiences with pain and effectiveness of pain management interventions.

2. “Nonpharmacological interventions are used to complement not replace pharmacological interventions” (Ackley et al., 2017, p.645). 3. Obtaining an individualized pain history helps identify potential factors that may influence the patient's willingness to report pain as well as factors that may influence pain (Ackley et al., 2017, p.640).

2. Goal met. Patient’s pain < 3/10 after ⅔ of meals utilizing nonpharmacological methods for pain control. Will continue current plan of care 3. Goal met. Patient’s pain < 3/10 after ⅔ of meals utilizing effective pain control schedule and nonpharmacological method. Will continue the current plan of care.

Patient will not have an occurance of aspiration during the entire shift.

1. Nurse will assess for pulmonary symptoms resulting from reflux of gastric content. 2. Nurse will assess the patient's ability to swallow and the presence of gag reflex by having the patient swallow a sip of water. 3. Nurse Will Avoid placing patient in supine position, have the patient sit upright after meals.

1.”Signs of aspiration should be detected as soon as possible to prevent further spiration and to initiate treatment that may be life saving” (Ackley et al., 2017, p.147). 2. “Safe nursing care includes consultation with a speech-language pathologist whenever doubts arise regarding a clients ability to tolerate oral-supported nutrition in any form”(Ackley et al., 2017, p.871). 3. “Decreased gastric reflux occurs at both 30- and 45-degree HOB elevation, so patients should maintain the highest HOB elevation that is comfortable to prevent aspiration” (Ackley et al., 2017, p.148).

1.Goal met. Patient did not aspirate during the entire shift. Will continue to reassess the respiratory system and plan of care.

2. Goal met. Patient did not aspirate during the entire shift and successfully passed swallow assessment. Will continue plan of care. 3. Goal met. Patient did not aspirate during the entire shift utilizing effective patient positioning recommendations. Will continue the plan of care.

References: Ackley, B. J., Ladwig, G.B., Makic, M. G. F., Martinez-Kratz, M. & Zanotti, M. (2017) Nursing diagnoses handbook: An evidence-based guide to planning care (12th ed.). St. Louis, MO: Elsevier. (Ackley et al., 2017, p.).

Reviewed & Revised 9/2020 by NCook...