FLORIDA MAE O.

FRANCISCO Nursing Care Plans: Gastric Outlet Obstruction secondary to tumor recurrence
RLE 3-4NUR4
Cues and Clues Nursing Diagnosis Objectives Nursing Interventions Rationale Evaluation
Subjective: Imbalanced Nutrition: Short term: 1. Note the patient’s 1. Various psychological After 8 hours of patient-nurse
- Patient Less than body After 8 hours of patient- perspective and feelings factors determine the interaction, the patient:
verbalized “Hindi requirements related to nurse interaction, the towards eating. type, amount and - Understood the significance
ako masyadong altered absorption patient will be able to: 2. Evaluate the environment appropriateness of food of nutrition in healing process
kumakain kasi - Understand the in which eating happens that will be utilized. and general health.
sumasakit lang significance of 3. Provide pleasant 2. Since the patient is an - Verbalized foods and meals
tiyan ko” nutrition in environment elderly, she may not that will increase body
- Abdominal pain healing process 4. Place patient in a semi- have the drive to weight.
graded 5/10 and general fowlers prepare a meal for
- Loss of weight health. 5. Schedule rest periods themselves. Long term:
- Verbalize foods before meals 3. A pleasing atmosphere After 1 week of patient-nurse
Objective: and meals that 6. Encourage helps in decreasing interaction, the patient:
- Pale, dry skin will increase companionship during stress and is more - Demonstrated behaviors,
- Poor muscle body weight. meal time favorable to eating lifestyle changes to recover
tone 7. Provide small frequent 4. Proper positioning aids from excessive weight loss or
- Dry, brittle hair Long term: feedings in swallowing and keep appropriate weight.
- Hyponatremia After 1 week of patient- 8. Note time of day when reduces risk for - Took adequate amount of
(125mEq/L) nurse interaction, the patient’s appetite is at aspiration calories or nutrients
- RBC- 3.8mcL patient will be able to: peak. 5. The patient may lack
- Loss of - Demonstrate 9. Encourage family strength so this will
subcutaneous behaviors, members to bring food conserve the patient’s
tissue lifestyle changes from home energy.
- Restlessness to recover from 10. Encourage a high protein, 6. Attention to social
excessive weight high caloric diet perspective of eating is
loss or keep 11. Discourage caffeinate or essential
appropriate carbonated beverages 7. Small feedings may be
weight. 12. Explain the importance of able to encourage
- Take adequate nutrition in healing patient to eat
amount of process 8. Offer the highest calorie
calories or meal at that time
nutrients
FLORIDA MAE O. FRANCISCO Nursing Care Plans: Gastric Outlet Obstruction secondary to tumor recurrence
RLE 3-4NUR4
9. Patients will be more
encourage to eat when
familiar food are served
10. High protein diet can
help maintain and build
lean muscle while high
caloric diet can provide
energy
11. These beverages will
decrease hunger and
lead to early satiety
12. Health teachings will
increase the patient’s
knowledge

‘
FLORIDA MAE O. FRANCISCO Nursing Care Plans: Gastric Outlet Obstruction secondary to tumor recurrence
RLE 3-4NUR4
Cues and Clues Nursing Diagnosis Objectives Nursing Interventions Rationale Evaluation
Subjective: Deficient fluid volume Short term: 1. Note skin turgor and oral 1. Signs of dehydration can Short term:
- Patient related to nausea and After 8 hours of nursing mucous membranes for be detected through the After 8 hours of nursing interventions,
verbalized vomiting interventions, the patient signs of dehydration skin. the patient:
“kalahating baso must be able to: 2. Note presence of nausea 2. These causative factors - Verbalized awareness of
palang naiinom - Verbalize and vomiting influence intake, fluid factors and behaviors
ko mula umaga” awareness of 3. Weigh daily with same need and replacement essential correct fluid deficit
- Generalized factors and scale and same time of 3. Weight is the best - Explained measures to treat
weakness behaviors the day assessment data for or prevent fluid loss
Objective: essential correct 4. Encourage to drink possible fluid volume
- Decreased urine fluid deficit prescribed amount of fluid imbalance After 3 days of nursing interventions,
output - Explain 5. Provide fluid and straw 4. Older patients have a the patient:
- Weight loss measures to eat bedside within reach. decreased sense of - Maintained normal fluid
- Tachycardia treat or prevent 6. Assist if unable to drink or thirst and may need volume as evidenced by
(111bpm) fluid loss eat without assistance reminders to drink systolic BP greater or equal
- Pale, dry skin 7. Emphasize the 5. To remind the patient to to 90mmHg, urine output
- Dry mucous After 3 days of nursing importance of maintaining drink constantly greater than 30ml/hr, normal
membranes interventions, the patient proper nutrition and 6. Dehydrated patients skin turgor and normal pulse
- Poor skin turgor must be able to: hydration may be weak and may rate/cardiac rate.
- Maintain normal 8. Educate the patient’s need assistance
fluid volume as family to monitor intake 7. Increasing the patient’s
evidenced by and output knowledge level will
systolic BP Collaborative: assist in preventing and
greater or equal 9. Insert IV catheter to have managing the problem
to 90mmHg, IV access as ordered 8. Accurate measure of
urine output 10. Maintain and regulate IV fluid intake and output is
greater than flow rate as ordered an important indicator of
30ml/hr, normal 11. Administer antiemetic as patient’s fluid status
skin turgor and ordered 9. Parenteral fluid
normal pulse replacement to treat or
rate/cardiac rate. prevent hypovolemic
complications
10. To prevent fluid overload
FLORIDA MAE O. FRANCISCO Nursing Care Plans: Gastric Outlet Obstruction secondary to tumor recurrence
RLE 3-4NUR4
11. To prevent patient from
vomiting
FLORIDA MAE O. FRANCISCO Nursing Care Plans: Gastric Outlet Obstruction secondary to tumor recurrence
RLE 3-4NUR4
Cues and Clues Nursing Diagnosis Objectives Nursing Intervention Rationale Evaluation
Subjective: Anxiety related to crisis After 3 hours of patient- 1. Validate 1. To establish rapport and After 3 hours of patient-nurse interaction,
- “Hindi na nga situation and changed in nurse interaction, the observations by encourage verbalization the patient:
masyadong health status patient will be able to: asking patient of feelings - Described her own anxiety and
nakakausap si - Describe own how she feels 2. This may help the patient coping patterns
nanay eh” as anxiety and 2. Observe how the feel like he or she is - Demonstrated ability to reassure
verbalized by the coping patterns patient uses contributing to her plan of self
family member - Demonstrate coping care
- Altered sleeping ability to techniques and 3. To promote After 1 day of patient-nurse interaction,
pattern reassure self defense communication the patient:
- Abdominal pain mechanisms to 4. To help in creating a plan - Identified strategies to reduce
Objective: After 1 day of patient- cope with anxiety of care anxiety
- Loss of appetite nurse interaction, the 3. Use presence, 5. This can increase the - Had posture, facial expressions,
- Increased pulse patient will be able to: touch with patient’s feeling of gestures ad activity levels that
rate (111bpm) - Identify permission, stability and calmness reflect decreased distress
- Fatigue strategies to verbalization and 6. To make the patient feel
- Restlessness reduce anxiety demeanor to secured and protected
- Difficulty in - Have posture, remind that she 7. To promote
concentrating facial is not alone understanding
- Diminished expressions, 4. Encourage 8. To promote calmness
motivation to gestures ad expression of and may decrease the
learn activity levels needs, concerns, anxiety of the patient
that reflect and questions 9. Obtaining insights allows
decreased 5. Interact in a the patient to reevaluate
distress peaceful manner the threat or identify new
6. Accept patient’s ways to deal with it
defenses, do not 10. This can help the patient
dare, argue or perceive the situation
debate realistically and
7. Converse using recognize factors leading
a simple to anxious feelings
language and
brief statements
FLORIDA MAE O. FRANCISCO Nursing Care Plans: Gastric Outlet Obstruction secondary to tumor recurrence
RLE 3-4NUR4
8. Provide a 11. Anxiety is a normal
peaceful response to actual or
environment perceived danger
9. Help patient 12. To provide patient with
determine variety of ways to
precipitant of manage anxiety
anxiety that may 13. Education can lessen the
indicate anxiety of the patient
interventions 14. To increase their
10. Encourage knowledge in identifying
patient to talk anxious responses and
about anxious can intervene earlier than
feelings otherwise
11. Use empathy to
encourage
patient to
interpret the
anxiety
symptoms as
normal
12. Assist in
developing new
anxiety or stress
reducing skills
such as deep
breathing
exercises,
positive
visualization
13. Explain all
activities,
procedures that
FLORIDA MAE O. FRANCISCO Nursing Care Plans: Gastric Outlet Obstruction secondary to tumor recurrence
RLE 3-4NUR4
involve the
patient
14. Educate the
family members
about symptoms
of anxiety and
how to help the
patient