Assessment Nursing Objective of Care Interventions Rationale Evaluation

Diagnosis

Subjective: Nutrition Short term: Independent Goal Met:

deficit At the end of my shift, 1. Monitor and 1. Ensures ongoing At the end of the shift,
Objective: related to the client will be able record dietary assessment of the patient consistently
vomiting to: intake, nutrition status maintained adequate
and including and guides liquid and nutrition
decrease - Patient will frequency, further intake, demonstrating
appetite maintain types of food interventions. compliance with
adequate consumed, and dietary
nutritional amount recommendations.
intake. tolerated. 2. Prevents
overwhelming the There were no more-
- Patient will 2. Offer small, digestive system, reports of vomiting
demonstrate frequent meals promotes steady throughout the shift,
improved and snacks to nutrient intake, indicating successful
tolerance to and reduces control of symptoms
promote intake
oral intake at vomiting triggers. and improved
the end of my and prevent tolerance to oral
shift. vomiting. 3. Maintains intake.
hydration,
provides The patient
essential demonstrated clear
3. Encourage electrolytes, and understanding of
- Patient will intake of clear prevents dietary modifications
report liquids between dehydration. and was able to
decreased meals to verbalize effective
frequency of maintain strategies to manage
vomiting hydration. symptoms, reflecting
episodes at the comprehension and
 end of my shift. readiness to implement
dietary changes.
- Patient will
demonstrate 4. Controls
improved Dependent: vomiting,
tolerance to improves comfort,
oral intake at 1. Administer and facilitates
the end of my antiemetic adherence to
shift. medication as dietary
prescribed by the recommendations
physician to .
control vomiting.
5. Develops a tailored
or specific meals
Collaborative: for the patient,
easily digestible
1. Collaborate with diet plan to address
dietitian to symptoms and
develop a ensure optimal
modified diet plan nutrition.
that is easily
digestible and low
in fat to alleviate
symptoms.