NURSING CARE PLAN

Cues Nursing Diagnosis Rationale to Nursing Goals and Objectives Nursing Interventions Rationale to Nursing Evaluation
Diagnosis Interventions
Subjective cues: Nutrition imbalanced Nausea and vomiting Short term range Independent: Short term:
“I cannot tolerate less than body are not diseases, but After 4-8 hours of The patient shall have
fluids because of requirements related to rather are symptoms of nursing intervention, 1. Auscultate 1. Inflation or demonstrated
nausea and vomiting, nausea and vomiting. many different patient will bowel sound, irritation of the behaviors to monitor
and I has liquid stools conditions, such as demonstrate behaviors noting absence intestine may fluids status and
2-4 times per day.” as infection (“stomach to monitor fluid status or hyperactive be reduce recurrence of
verbalized by the patience. flu”), food poisoning, and reduce recurrence sounds. accompanied fluid excess.
motion sickness, of fluid excess. 2. Eliminate smells by intestinal
overeating, blocked from the hyperactive,
intestine, illness, Long term range: environment. diminished Long term range:
Objective Cues: concussion or brain After 3 days of 3. Avoid foods that water After 3 days of
Physical Examination injury, appendicitis. nursing intervention might cause or absorption and nursing interventions,
Nausea and vomiting the client will be able exacerbate diarrhea the client will be able
o o can sometimes be to maintain usual abdominal 2. Reduces gastric to maintain usual
T: 38.6 C (101.5 F)
symptoms of more weight cramping like stimulation and weight
serious disease such as caffeinated vomiting
Pulse: 96 beats/min heart attacks, kidney Manifest stabilize beverages, response Manifested stabilized
or liver disorders, fluid volume AEB chocolate, 3. Might increase fluid volume AEB
central nervous system balance I & O, normal orange juice. abdominal balance I & O, normal
BP: 102/84 mmHg disorder, brain tumors, VS, stable weight, and 4. Measure cramping VS, stable weight, and
and some form of free from signs of abdominal girth 4. Provides free from signs of
cancer. edema. 5. Observe skin or Quantitative edema.
Diagnostic Data mucous evidence of
Source: Gil Wayne, membrane changes in
Urine specific gravity: dryness. And gastric or
1.035 BSN, R.N. (2017),
Impaired Gas turgor, note intestinal
Serum sodium: 145 Exchange Nursing peripheral edema distention
Care Plan, and sacral edema 5. Hypovolemia
mEq/L 6. Assess abdomen fluid shifts and
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 frequently for nutritional
Serum potassium: 3.5 return to deficits
mEq/L softness, contribute to
Chest x-ray: negative appearance of poor skin
normal bowel turgor
sounds, and edematous
passage of flatus tissue
Scant urine output
7. Weigh daily 6. Indicates return
 Dry oral 8. Monitor vital of normal
mucosa, sign bowel function
 furrowed and ability to
resume oral
tongue, intake.
 cracked lips 7. Initial losses or
gains reflect
changes in
hydration
8. To record if
there are any
changes

Dependent:
Administer antiemetics Dependent:
as ordered. Most antiemetics work
by increasing the
threshold of the
chemoreceptor trigger
zone to stimulation.
Drugs with antiemetic
actions include
 antihistamines,
anticholinergics,
dopamine antagonists,
serotonin (5-HT3)
receptor antagonists,
and benzodiazepines.
Glucocorticoids and
cannabinoids are
useful to treat
chemotherapy-induced
nausea and vomiting.
For the preoperative
patient, administration
of antiemetics prior to
surgery has been
shown to reduce
postoperative nausea
and vomiting.

Collaborative:
1. Monitor
BUN, 1. Reflect organ
protein function and
albumin, nutritional
glucose, status and
nitrogen needs.
balance 2. Careful
as progression of
indicated. diet when
2. Advance intake is
diet as resumed
tolerated. reduces risk of
gastric
irritation.