Assessment Diagnosis Inference Planning Intervention Rationale Evaluation

Independent:
Subjective: Nutrition Nutritional After 2days of -After 3days of
-Eliminate smell - Reduces gastric
imbalanced imbalance nursing form the nursing
stimulation and
“Nagsuka ako less than body intervention environment vomiting intervention
kanina.” As requirements the client will response. the client will
verbalized by related too be able to -Avoid foods that be able to
might cause or - Might increase
the patient. nausea and Dizziness maintain usual exacerbate
maintain usual
abdominal
vomiting. weight abdominal cramping.
weight.
Objective: cramping like
caffeinated
-Pale Nausea and beverages,
chocolate, orange
conjunctiva vomiting juice. - Hypovolemia,
and mucous fluid shifts and
membrane. -Observe skin or nutritional deficits
-Pale in mucous contribute to poor
membrane skin turgor.
appearance
dryness, and
-Weak turgor. Note: - Initial losses or
peripheral edema. gains reflect
-V/S taken as changes in
follows: -Weigh daily. dehydration

Collaborative:
T: 36.5
RR: 22 -Monitor BUN, - Reflects organ
CP: 76 protein, glucose function and
nitrogen balance. nutritional status
BP: 130/80 and needs.
-Advance diet as
tolerated - Careful
progression of
diet when intake
is resumed
reduces risk of
gastric irritation
-
Cruz, Paolo Martin M.
NCM 202 – RLE. N
Nursing Care Plan