Assessment Explanation of the
Problem
Subjective Data:
“I haven’t been able to eat
for four days.”
“I was trying to vomit in the
emergency department.”
 Reports weight loss
of about 5 lbs. since
becoming ill.
 Reports last bowel
movement was 2
days ago.
 Complains of
generalized
abdominal cramping
Objective Data:
 With an ongoing IV Nutrition: Less
for hydration and
electrolyte Requirements
replacement in her
right arm.
 Abdomen is slightly
distended and
tender to palpation.
 Hypoactive bowel
sounds noted.
Nursing Dx.:
Imbalanced Nutrition: less
than body requirements R/T
inability to ingest food
Nursing Goals Nursing Intervention
Intractable Long Term Goal: Diagnostic:
Vomiting The client will be able  Determine etiologic factors for
to demonstrate reduced nutritional intake.
↓ behaviors to recover  Monitor response to different
Generalized and/or regain food or food preparation
abdominal appropriate weight
cramping after 3 days of nurse- Therapeutic:
patient interaction.  Provide good oral hygiene before
↓ and after meals.
 Provide pleasant, relaxed
Inability to Short Term Goal: atmosphere for eating (no
ingest food The client will consume bedpans in sight; don’t rush;
adequate nourishment provide mellow music if desired)
↓ as evidenced by  Provide companionship at
consuming at least 2/3 mealtime to encourage
Imbalanced of the meal served, nutritional intake.
after 4 of nursing
Than Body management.  Offer frequent small feedings
 Administer antiemetics and pain
medications as ordered and
needed before meals.
 Instruct client to avoid overly
sweet, rich, greasy, or fried foods.
Educative:
 Help the client identify the area to
change that will make the greatest
contribution to improved
nutrition.
 Build on the strengths in the
client’s food habits. Adapt
changes to her current practices.
Scientific Rationale Evaluation
The goals were met.
 Proper assessment guides intervention. The client was able to
 To identify patient’s food consume everything
preferences/dislikes which may that was in the meal
contribute to her decreased oral served after four hours
intake. of nursing management.
 It enhances good appetite and
better taste of the food. She is also able to
 A pleasing atmosphere helps in demonstrate behaviors
decreasing stress and helps promote to recover and/or regain
intake. appropriate weight such
as frequent intake of
 Mealtime usually is a time for social small feedings and
interaction; often clients will eat avoidance of rich, overly
more food if other people are sweet, and greasy food.
present at mealtimes
 Eating small, frequent meals lessens
the feeling of fullness and decreases
the stimulus to vomit.
 To control nausea and pain before
meals to make the meal a pleasant
experience.
 This group of foods can cause or
aggravate nausea.
 Change is difficult, thus multiple
changes may be overwhelming.
 Accepting the patient’s preferences
shows respect for her.