NRSG199 - Prep and Plan 4 PDF

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Prep and Plan for Clinical...

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Prep and Plan Medical-Surgical Diagnoses:  GERD (Gastroesophageal reflux disease)  GERD occurs when the stomach acid frequently flows back into the esophagus connecting the mouth and stomach. This backwash (acid reflux) can irritate the lining of your esophagus. Anticipated assessment data for this patient: 1. inadequate food intake 2. altered taste 3. nausea and vomiting 4. regurgitation 5. dysphagia 6. pain after food consumption List 2 priority “NANDA” Nursing Diagnoses based on the above assessment data: 1. Imbalanced Nutrition: Less than body requirements 2. Risk for Aspiration Identify specific nursing interventions to support these priority nursing diagnoses: (action plan) 1. Encourage small frequent meals of high calories and high protein foods 2. Instruct patient to eat slowly and masticate foods well 3. Accurately measure the patient’s weight and height. 4. Assess for nocturnal regurgitation 5. Elevate HOB while in bed 6. Assess patient’s ability to swallow and the presence of gag reflex. Have the patient swallow a sip of water Based on your prep & plan what will you pay special attention to: (What do you see as the patient’s priority issue?)  I see risk for aspiration and imbalanced nutrition as my patient’s priority issues. I will pay close attention to my patient’s food consumption and pain after meals. Along with teaching my patient to keep the bed elevated at 45 degrees after consuming a meal to help avoid the risk of aspiration. Also, I will remind my patient to eat meals of high caloric intake and high protein.

What teaching do you think your patient will require?  I think my patient will require teaching with keeping the head of the bed elevated at 45 degrees after food consumption. I would make little reminders to help my patient to remember to elevate the head of the bed. Along with teaching my patient to eat slowly and making sure my patient chews food well. By teaching these to the patient it will help to decrease the risk for aspiration and imbalanced nutrition. References: http://www.nandanursingdiagnosislist.org https://nurseslabs.com/gastroesophageal-reflux-disease-gerd-nursing-care-plans/4/...