Jordan Gonzales

Nur77- Umali
2-29-16

NCP Acute Gastritis

Case: Sheila Mae Jimenez, a 7-yr old girl, was admitted to PPH on Feb 20, 2016 w/ chief complaints of stomach pain.
Assessment
Nursing
Nursing Analysis Planning
Implementation
Rationale
Evaluation
Diagnosis
S: "My stomach Pain r/t
The patient has
Short term
Dependent
Dependent
Short term
hurts"
inflammation or acute gastritis.
The patient's
1. The patient
1. Antacids help Goal met: The
irritation of the
Acute gastritis is abdominal pain
will receive
give relief from
patient's
O:
gastric mucosa
inflammation of will go away
antacids.
gastric acid
abdominal pain
-Abdominal pain due to increased the stomach
after 1 wk.
2. The patient
2. Cytoprotective went away after
w/ a pain scale
gastric acid
lining. Common
will receive
agents protects
1 wk.
of 5/10
causes are the
cytoprotective
the lining of the
bacteria H.
agents
stomach & small
pylori &
3. Review the
intestine
NSAID's. It may
level of pain
3. To determine
also occur from
the patient's
surgery, trauma,
Independent
level of pain
or severe
1. Try to avoid
infection. The
food that
Independent
main symptom is
stimulate an
1. Determines
usually (upper
increase of
food that
central)
stomach acid
increase stomach
abdominal pain.
acid; reduces
Possible
gastric acid
symptoms
include nausea,
vomiting, &
appetite loss.
Submitted by: Jordan Gonzales
Submitted to: Carlo Umali

Jordan Gonzales
Nur77- Umali
2-29-16

NCP: GERD
Case: Lovely Nicole Julie, an 8-yr old girl, was admitted to PPH on Feb 11, 2016 w/ chief complaints of frequent vomiting & cough.
Assessment
Nursing
Nursing Analysis Planning
Implementation
Rationale
Evaluation
Diagnosis
S: "I keep
Altered comfort: The patient has
Short-term
Dependent
Dependent
Short term
vomiting
dyspepsia r/t
gastroesophageal 1. Patient's
1. Patient
1. Reduce gastric Goal not met:
constantly. I also impaired GI
reflux disease
GERD will go
receives proton- acid production
Patient still has
have cough."
functioning AEB (GERD). GERD away after 2
pump inhibitors 2. Block
GERD after 2
coughing &
is the chronic
months.
2. Patient
histamine
months
O:
vomiting
condition of
2. Patient will be receives H2stimulation of
Goal met:
-Regurgitation
stomach acid
relieved of
receptor blockers stomach acid
Patient was
-Dysphagia
escaping the
dysphagia after 2 3. Patient
production (in
relieved pf
-Coughing
stomach &
weeks
receives antacids parietal cells)
dysphagia after 2
damaging the
3. Patient will no 4. Patient will
3. Neutralize
weeks
esophagus. It's
longer cough
follow doctor's
stomach acid;
Goal met:
caused by
after 1 week
orders (for meds relieve heartburn Patient no longer
dysfunction of
& dietary
4. You need to
has cough after 1
the cardiac
changes)
follow the
wee
sphincter
doctor's
between the
Independent
healthcare plan
stomach &
1. Patient eats
to get better
esophagus.
upright
Symptoms
Independent
include repeated
1. Reduces
vomiting,
reflux
effortless
spitting up
(babies), &
coughing.
Submitted by: Jordan Gonzales
Submitted to: Carlo Umali

Jordan Gonzales
Nur77- Umali
2-29-16

NCP: Acute Gastroenteritis

Case: Jamela Dela Cruz, an 11 month baby girl, was admitted to PPH on Feb 10, 2016 w/ chief complaints of diarrhea & vomiting
Assessment
Nursing
Nursing Analysis Planning
Implementation
Rationale
Evaluation
Diagnosis
S: " I have
Acute pain r/t
The patient has
Short term
Dependent
Dependent
Short term
diarrhea &
ingestion of
acute
1. Patient's
1. Monitor input 1. Make sure
Goal met:
vomiting. My
toxic substance
gastroenteritis.
gastroenteritis
& output
stool frequency
Patient's
stomach hurts."
AEB passage of Gastroenteritis is will go away
2. Patient takes
isn't high
gastroenteritis
loose watery
infection of the
after 2 weeks
full course of
2. Full course of went away after
O:
stool, poor skin
stomach & small 2. Patient will
medication
medication will
2 weeks
-Watery stool
turgor, irritability intestine.
stop vomiting
get rid of the
Goal met:
-Increased
Symptoms
after 1 week
pathogen
Patient stopped
frequency of
include diarrhea, 3. Patient will no Independent
vomiting after 1
stool
vomiting, &
longer have
1. Patient will
Independent
week.
-Cold, clammy
abdominal pain. diarrhea after 1
practice
1. Reduces
Goal met:
skin
Fever,
week
handwashing
chance of
Patient n longer
-Irritability
dehydration, &
Long term
2. Patient drinks infection from
has diarrhea after
low energy may 1. Patient will do lots of water
gastroenteritis
1 week
also occur. This
personal
3. Patient limits
2. Water helps
Long term
usually lasts less handwashing
caffeine, hi-fiber clean GI tract;
Goal met:
than 2 weeks.
after 1 year
food, & fatty
replaces fluid
Patient performs
food
3. Prevent
handwashing
4. Patient does
gastric irritation after 1 year
relaxation
4. Stress &
techniques to be anxiety
more relaxed
aggravate
diarrhea
Submitted by: Jordan Gonzales

Submitted to: Carlo Umali

Jordan Gonzales
Nur77- Umali
2-29-16

NCP: Celiac Disease

Case: Bernabe De Guzman, an 11yr old boy, was admitted to PPH on February 25, 2016 w/ chief complaints of abdominal pain,
diarrhea, & fatigue.
Assessment
Nursing
Nursing Analysis Planning
Implementation
Rationale
Evaluation
Diagnosis
The patient has
Independent
S: "I have
Imbalanced
Short term
Independent
Short term
celiac
disease.
1. Gluten damages
fatigue. I also
nutrition: less
1. Patient will be 1. Patient has a
Goal met:
Celiac disease is an
the villi in the small
have diarrhea & than body
healthier after 2
lifelong glutenPatient is
autoimmune
intestine, & no
my abdomen
requirements r/t disorder affecting
months
free diet
healthier after 2
medication exists
hurts."
malabsorption
months
the small intestine.
for celiac disease.
The small intestine
AEB wt loss,
2. Patient will
2. Patient avoids Depending on the
Goal met:
becomes
damaged
patient's
sensitivity,
O:
diarrhea, watery
stop eating
food w/ wheat,
Patient stopped
by gluten (proteins
large amounts of
-Wt loss
gray stool,
gluten
after
6
rye,
&
barley
eating gluten
in wheat & other
gluten can be very
-Diarrhea
abdominal pain, grains). GI
months
(some flours,
after 6 months
damaging. Small
-Watery, foul,
& body
pasta, bread,
symptoms include
amounts of gluten
pale (fatty)
everyday can also
gray stool
weakness
Long term
cake, cookies,
Long term
malodorous
cause
damage.
-Large amounts
1. Patient will
cereal, sauces,
Goal met:
diarrhea, abdominal
of intestinal gas
stop
eating
beer,
crackers,
Patient stopped
pain, cramping, &
2. Wheat, rye, &
-Abdominal pain
gluten after 1 yr etc.)
eating gluten
bloatedness. Celiac
barley contain
-Body weakness
3. Patient checks gluten.
after 1 yr
disease can also
cause nutrient,
the nutrition
vitamin, & mineral
3. Patient needs to
labels of food
deficiencies (leading
be aware of whether
(for wheat, rye,
to many
gluten exists in his
& barley)
malabsorptionfood
4. Patient eats
related symptoms)
4. Prevents small
fruits,
intestine from
vegetables,
getting damaged;
beans, dairy, nuts allows intestine to
or other glutenheal
free food