Pelagio, Shiena Mae B. Prof.

Ulitin

BSN 2-A March 1, 2020

CASE STUDY #1

NURSING CARE PLAN

Assessment Diagnosis Planning Implementation Evaluation

Subjective: Imbalanced Nutrition: After 3 days of nursing Independent: After the nursing
 Stated that Less than body interventions, the  Note age, interventions, the
she was nauseated requirements related client will be able to body build, client demonstrate
to inability to ingest, demonstrate progressive weight gain
and vomited strength, activity
digest, or absorb progressive weight gain toward goal and
frequently nutrients (prolonged toward goal and level, and current demonstrate
throughout the vomiting) as demonstrate condition or behaviors, lifestyle
day. evidenced by weight behaviors, lifestyle treatment needs. changes to regain
 After two loss changes to regain Helps determine and/or maintain
weeks, she stated and/or maintain nutritional needs. appropriate weight.
appropriate weight.
that her nausea  Promote
and vomiting is adequate and
now severe. timely fluid
intake. (Limiting
fluids 1 hour prior
to meal
Objective:
decreases
 Pallor
possibility of
 Increased
early satiety.)
ketones in the
 Instruct the
urine
patient to avoid
 increased
foods that cause
urine specific
intolerances or
gravity
increase gastric
 abnormal
motility according
sodium and
to individual
potassium levels
needs.
 dry tongue
 Suggest
 BP: 88/60 mm
alternative
Hg
dietary patterns
(e.g., frequent
small and dry
meals, six or more
per day, followed
 by clear liquids).
Small, frequent,
dry meals may
reduce nausea
and vomiting
from a distended
stomach.
 Assist with or
provide oral care
before and after
meals and at
bedtime. To
maintain the
integrity of the
oral mucosa.

Dependent
 Administer
pharmaceutical
agent (e.g.,
antiemetic) as
ordered. To
decrease nausea
and vomiting