Nursing Diagnosis:
Potential for pain and heartburn related to an open area that is exposed to acid as evidence by chest pain, burning in the throat, difficulty swallowing and facial grimacing.
Assessment
Assess for abdominal guarding.
Assess for restlessness.
Assess pain for 6 or higher out of 10.
Assess vitals to be within normal ranges for the patient.
Any verbalized complaints made by patient.
Assess for restlessness.
Assess pain for 6 or higher out of 10.
Assess vitals to be within normal ranges for the patient.
Any verbalized complaints made by patient.
Smart Plan
By April 7,2014 at 1300 the patient will be free from any discomfort or pain felt from heartburn. They will have a pain rating of 3 or less out of 10.
Nursing Interventions
1. Encourage the patient to have small frequent meals.
2. Encourage patient to stay in a position of comfort.
3. Keep patients bed upright for 2-3 hours after eating.
4. Review foods that aggravate pain.
5. Limit foods that create discomfort.
6. Encourage patient to follow any dietary restrictions set.
2. Encourage patient to stay in a position of comfort.
3. Keep patients bed upright for 2-3 hours after eating.
4. Review foods that aggravate pain.
5. Limit foods that create discomfort.
6. Encourage patient to follow any dietary restrictions set.
Evaluation
Patient report no pain. Patient teaching about which foods to not eat was given, and they are following the restrictions.