[Institution Title]
Care Plan Template
Patient Initials: N/A Age: 60 yrs. old Sex: MAle
Subjective Data:
HPI (History of Present Illness): Patient has been experiencing heartburn during the past 2 weeks. Patient said to experience heartburn after eating. It is relieved after a few hour or after taking over the counter antacid. According to patient, the pain seems to progress. It started in the umbilical region and is now diffused. Patient said that he was partly relieved after sitting down. However, the pain has become unbearable that he rated it 10 during the actual attack.
PMH (Past Medical History—include current medications, any known allergies, any history of surgery or hospitalizations): Patient reports no known allergies. In addition, patient was also treated for the following medical condition: hypercholesterolemia, hypertension, and gout. Patient had an appendectomy 20 years ago. Among patient’s prescribed medications include Indocin 50 mg Q 6 hours PRN gout symptoms, Zocor 20 mg QD, Propranolol 50mg BID. However, patient admits that he is not taking the medication because he was concerned about potential side effects. Nevertheless, since patient starts experiencing gout symptom, patient has been taking Indocin again for the past one month. Patient also goes to alternative medicine, particularly Saint John’s for depression and admits to taking a capsule 3 times a day but has not noted any significant changes as far as his symptoms are concerned.
Significant Family History: Patient’s wife has osteoarthritis of both knees and hips. Patient’s father has a heart condition which caused the latter’s death about the same age as the patient is now causing anxiety to patient. Patient has not spoken about his mother or siblings.
Social/Personal History (occupation, lifestyle—diet, exercise, substance use) Patient is a retired educator but has still been doing some teaching on the side. Patient used to be active physically but not after his symptoms of gout started manifesting again. Patient denies using street drugs. Patient does not smoke but consumes wine daily. Patient’s on few occasion drinks about 4 to 5 glasses of wine. While patient says that his wife always tries to cook healthy meal, patient admits to eating from fast foods frequently. According to patient, he has not been socializing much, although he wants to get involved with the community because he believes it will alleviate his depression.
Description of Client’s Support System: Patient’s support system included wife and two fully grown children. He also included his peers from his work which he still meets regularly. Although patient does not suffer from social isolation, he wants to be more involved in the community.
Behavioral or Nonverbal Messages: Patient has concerns about taking prescribed medication because of side effects. However, patient is not hesitant to take over the counter medication for his heartburn episodes. In addition, patient delays seeking medical attention unless he is in excruciating pain. Patient is open to alternative medicine.
Objective Data:
Vital Signs including BMI: BP: 175/70; Temperature is at 99°F taken orally; Pulse: 64 bpm, normal and regular; R: 18 and non-labored, WNR
Physical Assessment Findings: ROS all normal except for review of gastrointestinal region. Patient shows +bowel sound in all quadrants. Resonant to percussion throughout. Sharp pain with palpation at the epigastric region, radiating to the back. No HSM. No peritoneal signs.
Lab Tests and Results: Liver Function Test = negative, CBC = normal, Amylase & Lipase are within normal limits. However, patient tested positive for H. pylori.
ICD-9 Diagnoses/Client Problems:
- ICD-9 V790 Screening for depression
- ICD- 9 53530 Alcoholic gastritis, without mention of hemorrhage
Advanced Practice Nursing Intervention Plan (including interdisciplinary collaboration, community resources and follow-up plans):
- Need for emotional group involvement
- Depression
- NIC 5430 Support Group
While patient acknowledge the presence of his families and friends, patient still feels depress. Patient need to broaden his support group by getting involved in community activity.
Rationale: This will help patient fight off the depression because after retirement he might felt a little overwhelmed by the changes. He needs to feel needed by people like he once did when he was teaching.
- Pain Management
- Patient is experiencing excruciating pain requires alleviation from pain
- NIC 2210 Analgesic Administration - use of pharmacologic agents to reduce or eliminate pain
Rationale: patient rated pain as 10 to 7. This is significant values which might not be relieved easily and might require medication. This will help patient relieve the anxiety and stress that is further aggravating his condition.
- NIC 1400 Pain Management - alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient
Rationale – the pain is adding to the acute gastric condition of the patient because stress is a precursor to the physical symptoms of alcoholic gastritis,.
- Change in lifestyle
- Patient’s drinking habits should be stopped because it is causing his acute gastritis
- NIC 4500 Substance Use Prevention - prevention of an alcoholic or drug use lifestyle.
Patient is consuming wine on a daily basis and it is further aggravating his alcoholic gastritis. Patient should be taught that drinking wine should only be done on a full stomach.
References
Seibert, A. (2012, June 16). Digestive Disorders Health Center: H. pylori (Helicobacter pylori). Retrieved from WebMD Website: http://www.webmd.com/digestive-disorders/h-pylori-helicobacter-pylori#2
Wehbi, M. (2014, September 18). Acute Gastritis . Retrieved from Medscape Website: http://emedicine.medscape.com/article/175909-overview
