Question

Nursing diagnosis ( must have 3)	Goal ( Measurable, specific timeline)	Interventions ( include 3 for each diagnosis: Assess, monitor, teach)	Rationale ( Reason for this intervention)	Evaluation ( Met, partially met, not met and explain the progress
1.
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Complete a care plan on the patient you performed on the nutritional assessment on with the focus being nutrition

Answer 1

#. Nursing care plan :-

1. Imbalanced nutrition: less than body requirements related to vomiting and loss of appetite as manifested by low protein level .

Planning and Outcome:

Short term:

The patient will experience relief from nausea and vomiting in 2-4 hours

Long term:

The patient will experience good appetite after two days of nursing interventions.

Nursing interventions and rationale:-

Independent:

– Assess and document amount, color, and characteristics of vomitus – Determine fluid replacement

– Eliminate smells from the environment Reduces gastric stimulation and vomiting response

– Monitor the BUN, protein, and glucose balance as indicated. – Reflect organ function, nutritional status and needs

– Adjust diet according to nutritional needs and patient’s preferences – Taking patient’s food preferences would help him gain a good appetite

Dependent:

– Administer antiemetic drugs – Prevent loss of stomach contents

Evaluation:

Goal met:

The patient’s nausea and vomiting stopped after administering antiemetics.

The patient’s appetite has progressively improved.

2. Deficient fluid volume related to prolonged vomiting and inability to ingest, digest, or absorb food and fluids as evidenced by decreased urine output and increased urine concentration, increased pulse rate, hypotension (postural), decreased intake, decreased skin turgor, and dry skin and mucous membranes

Expected outcomes :-

- Shows no signs of dehydration

Nursing interventions and rationale :-

- Assess for signs of dehydration to plan appropriate care.

- Administer and monitor the amount and type of IV fluid to maintain fluid and electrolyte balance .

- Administration of antiemetics to stop vomiting

- Monitor the input and output ratio to assess the fluid status

- Avoid sources that cause nausea like odours ,visual stimuli, foods etc to avoid trigger of vomiting.

- Provide a quiet environment ,minimise procedure that trigger vomiting .

- Provide mouth care to maintain good mouth hygiene

- Advice the patient to take small frequent diets and fluids to avoid back flow and promote digestion.

- Avoid sudden change of position and keep head elevated to avoid vomiting

3. Knowledge deficit related to the foods to be taken during nausea and vomiting as evidenced by avoiding all the foods that were provided him to eat .

Patient outcome :

To make him understand and provide knowledge about the foods to be taken during nausea and vomiting

The patient will be able to tell what all foods have to be taken while vomiting

Nursing interventions :-

- Advice patient to have small frequent diet to avoid backflow and promote digestion .

- Advice to have soft or liquid diet to maintain fluid status and avoid more exertion of the stomach by having solid diet .

- Have food that are in chopped , mashed form

- Advice to have lot of fluids in the form of juices , soups ,plain water etc