Prado, Catherine A.

BSN 1-H

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE:  Nausea related to After series of nursing INDEPENDENT After the nursing
 When did it begin? deficient fluid intervention, the client will  Avoid foods that intervention, was the client
 How bad it is? volume. be able to: might cause or able to:
 What makes it better  Loss of appetite due  Tolerate clear liquids exacerbate  Tolerate clear liquids
or worse? to abdominal pain. within 12 hours abdominal cramping within 12 hours
 How many times that  Deficient fluid without any nausea like caffeinated without any nausea
you vomit? volume related to or vomiting. beverages, or vomiting.
 Are you taking vomiting.  Decrease in nausea chocolate, orange  Decrease in nausea
supplements like  Acute pain due to within in 6 hours. juice. within in 6 hours.
slimming pills?  Be free of nausea  Be free of nausea
 What did you eat and vomiting  Asses pain and vomiting
before it happened? completely. completely.
 Did you take any  Improve appetite  Asses bowel sound  Improve appetite
medications? and movements
 Do you drink coffee
or other beverages  The nurse will assess
that contains the patient’s nausea
caffeine? If yes, how every 2-3 hours.
often?
 What do you do for  Observe if paleness is
leisure and still visible.
recreation?
 How was your bowel  Assess abdomen
movement and frequently for return
bowel sounds? to softness,
OBJECTIVE: appearance of
 Vomiting normal bowel sounds
 Pale Conjunctiva and movement.
 Abdominal pain
 Nausea  Record intake and
 V/S taken as follows: output.
T: 98.6 F
P: 98 DEPENDENT
Prado, Catherine A. BSN 1-H

R: 20  The nurse will

BP: 130/80 administer Zofran
4mg IV every 6 hours
as needed for nausea
and vomiting as
ordered by the
physician.
 Administer
medications as
appropriate