NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Independent:
Subjective: • Nutrition • Nausea and • After 3 days. • Auscultate bowel • Inflammation or • After 3
imbalanced vomiting are not Of nursing sounds, noting irritation of the days. Of
“Nagsusuka ako” less than diseases, but interventions, absence or intestine may nursing
as verbalized by body rather are the client will hyperactive be intervention
patient. requirements symptoms of be able to sounds. accompanied s, the client
related to many different maintain by intestinal will be able
Objective: nausea and conditions, such usual weight. hyperactivity, to maintain
vomiting. as infection diminished usual
• Hyperactive ("stomach flu"), water weight.
bowel food poisoning, absorption and
sounds. motion sickness, diarrhea.
overeating, • Eliminate smells • Reduces gastric
• Pale blocked from the stimulation and
conjunctiva intestine, illness, environment. vomiting
and mucus concussion or response.
membrane. brain injury, • Avoid foods that • Might increase
appendicitis, and might cause or abdominal
• V/S taken as migraines. exacerbate cramping.
follows: Nausea and abdominal
vomiting can cramping like
T: 36.6 sometimes be caffeinated
P: 98 symptoms of beverages,
R: 18 more serious chocolate, orange
Bp: 110/90 diseases such juice.
as heart attacks, • Measure • Provides
kidney or liver abdominal girth. quantitative
disorders, evidence of
central nervous changes in
system gastric or
disorders, brain intestinal
tumors, and distention.
some forms of • Observe skin or • Hypovolemia,
cancer mucous fluid shifts and
membrane nutritional
dryness, and deficits
turgor. Note contribute to
peripheral edema poor skin
 and sacral turgor,
edema. edematous
tissue.
• Assess abdomen • Indicates return
frequently for of normal bowel
return to softness, function and
appearance of ability to
normal bowel resume oral
sounds, and intake.
passage of flatus.
• Weigh daily. • Initial losses or
gains reflect
changes in
hydration.

Collaborative:
• Monitor BUN, • Reflects organ
protein, function and
prealbumin or nutritional
albumin, glucose, status and
nitrogen balance needs.
as indicated. • Careful
• Advance diet as progression of
tolerated. diet when
intake is
resumed
reduces risk of
gastric irritation.
Collaborative:
• Refer to physical
therapy.