[Institution Title]
Care Plan Template
Patient Initials: Not Applicable Age: 60 y/o Sex: Male
Subjective Data:
HPI (History of Present Illness): Patient said that the abdominal pain started the day before. Although patient admitted to experiencing similar discomfort in the past, patient did not experience this kind of pain which he rated as 10 from last night. In the past, the pain would only last for a couple of hours unlike this time which has not been relieved despite 24 hours had already passed. Patient also admits to experiencing nausea but has not vomited despite feeling nauseous. For the past two weeks patient has experienced heartburn which he fears could be heart attack. The heartburn according to pain increases after eating. Heartburn gradually resolves by itself or sometimes patient take over-the-counter antacids.
PMH (Past Medical History—include current medications, any known allergies, any history of surgery or hospitalizations):
Patient is unaware of any known allergy to medicine. Patient is being treated for hypercholesterolemia, hypertension, and gout, for which he was prescribed to take Indocin 50 mg every 6 hours as needed to relieve of gout symptoms, Zocor 20 mg once daily for his hypercholesterolemia and Propranolol 50mg taken twice daily for his hypertension. However, patient said he stopped taking the medicines because he feared of the side effects and possible complications of the medicines. But patient said he started back on Indocin for the last month because he starts experiencing gout symptoms again. There were also reason to assume that he might be overtaking Indocin. Patient is also to alternative therapy. In fact, patient admitted to be experimenting with Saint John’s wort and is taking three capsules thrice daily to help him with his depression. However, patient noted that no significant improvement can be noted from taking the medication. Patient also had an appendectomy 20 years ago and no complications had been noted. Patient recalled that as a child he was once diagnosed by a “stomach problem” but could not elaborate what it was. As mentioned earlier, patient treats his heartburn with over-the-counter medications.
Significant Family History: Patient confided that his family had a long history of gout. In addition to gout, his two older brothers also had hypertension and hypercholesterolemia which was diagnosed when both were in their early fifties. Patient’s father dies of heart attack at about the age that the client was presently at. This makes patient’s anxious everything he experiences heartburn.
Social/Personal History (occupation, lifestyle—diet, exercise, substance use):
Patient is a retired school teacher but still teaches on the side. He has a master’s degree in education while his wife works at a local supermarket. The couple earns $50,000 together and they believe they do not have sufficient money for travelling. Patient says his wife cooks healthy food but patient still frequently dines on fast food restaurants. Patient do not smoke nor does he consume street drugs. However, patient admitted to consuming a glass of wine daily. On some instances patient has the tendency to drink more the one glass exceeding t 4 to 5 glasses.
Description of Client’s Support System: Patient support system includes wife, two children, and his two older brothers. Patient also acknowledge his former colleagues as his support group.
Behavioral or Nonverbal Messages: Patient does not believe that he needs to modify his lifestyle and behavior to be healthy. The patient also admits that he refuse to continue with the prescribed medication because he fears of the side effects. He also believes in alternative therapy. Patient take over-the-counter medications to alleviate symptoms of heartburn and hyperacidity.
Objective Data:
Vital Signs including BMI: Patient’s vital signs are all within normal value. Temperature was at 99°F. Pulse was recorded at 64 bpm, regular pace. Respiratory rate was recorded at 18 breaths per minute and characterized as non-labored. Blood pressure was at 175/70 taken from the right arm, sitting down. Patient’s blood pressure is elevated.
Physical Assessment Findings: No significant findings noted during physical assessment except for + bowel in all quadrant reporting as 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: Patient was tested for bacterial infection and patient tested positive for H. pylori. Other laboratory exams reported normal findings.
ICD-9 Diagnoses/Client Problems: Patient’s primary issues is perceived to be Alcoholic gastritis, without mention of hemorrhage with code ICD- 9 of 53530. Also patient complains of ICD-9 V790 Screening for depression. Other previous existing diagnosis include 40951 unspecified renovascular hypertension.
Advanced Practice Nursing Intervention Plan (including interdisciplinary collaboration, community resources and follow-up plans):
- Patient needs to modify behavior to a healthier lifestyle.
- NIC 4360 Behavior Modification – this is done to promote behavior change
Patient should stop taking over-the-counter medication. He needs to know whether the medication he will take will not harm him or further aggravates his gastric condition.
- NIC 4500 Substance Use Prevention –supportive care of patient/family members with physical and psychosocial problems associated with the use of alcohol or drugs. Patient’s drinking habits are causing him physical symptoms of gastritis.
- Patient need social involvement and community participation
- NIC 5430 Support Group – use of group environment to offer emotional support. Patient reported experiencing depression. This could potentially be caused by patient’s retirement that he is starting to feel that he still not over his previous role in the community as a school teacher.
- Pain Management to help patient mange physical discomfort or pain.
- NIC 1400 Pain Management – patient must be able to control his pain to a level that he is still able to function effectively and for his rest not to be affected by the pain.
- NIC 2210 Analgesic Administration. – use of pharmacologic agent to control pain. Patient must be taught on the proper dose and administration of medication as well as the precautions about taking analgesics.
- Monitoring, control and health identification
- NIC 6610 Risk Identification - evaluation of potential risk, identification of health risks, and prioritizing of risk saving strategies. Patient has elevated cholesterol level, high blood pressure, gout and heartburn. All are associated with patient drinking habits and binging on fast foods. Acknowledge need to refer patient to dietician for proper diet and cardiologist to evaluate heart condition. Patient is at high risk given his family history of heart condition.
References
Uppal, R., Lateef, S., Korsten, M., Paronetto, F., & Lieber, C. (1991). Chronic Alcoholic Gastritis: Roles of Alcohol and Helicobacter pylori. Archives of Internal Medicine, 760-764.
Wolff, G. (1970). Does alcohol cause chronic gastritis? Scandinavian Journal of Gastroenterology, 289-291.
