Nursing care plan

Patient name: Miss M Age: 36 years Sex: female

Diagnose: urinary stone Date of Admission: not available
Nursing Diagnose Objectives Nursing Intervention Evaluation
( ) Actual (✓ ) Short Term Objectives: Assessment: Objectives are:
Potential Within 1hour 1. Note real, exact weight; do
Risk for imbalanced Patient takes adequate not estimate ( ) archived
nutrition:less than Body amount of calories or 2. Take a nutritional history ( ) partially achieved
requirements nutrients with the participation of (✓ ) not achieved
Related to significant others.
Nausea and vomiting 3. Review laboratory values
As evidenced by:
Secondary to that indicate well-being or
deterioration
4. Review laboratory values
that indicate well-being or
deterioration (Serum
albumin-RBC and WBC
counts-Serum electrolyte
values)
Subjective data: Long Term Objective: Nursing Intervention:
The patient said she has Within one week: 1. Provide frequent, small feedings.
nausea and vomiting Patient maintains 2-Give client a list of permitted
weight or displays foods and fluids and encourage
weight gain on the way involvement in menu choices.
to preferred goal, with 3-Offer frequent mouth care provide
normalization of gum, hard candy, or breath mints
laboratory values between meals.
Patient demonstrates 4-Weigh daily, preferably in the
behaviors, lifestyle morning before breakfast.
changes to recover 5-Monitor laboratory studies, such as
and/or keep appropriate BUN, albumin, transferrin, sodium,
weight. and potassium.
6-Consult with dietitian or
nutritional support team.
7-Provide high-calorie, low- or
moderate-protein diet.
Include complex carbohydrates and
fat sources to meet caloric
needs (avoiding concentrated sugar
sources) and to
provide essential amino acids.
Restrict potassium, sodium, and
phosphorus intake, as indicated.
8-Administer medications as
indicated, for example:
Iron preparations
Calcium carbonate
Vitamin D
B complex and C vitamins and folic
acid
Objective data: Patient Health teaching:
Hemoglobin: 10.3 Teach the patient
mg/dl 1. Mouth care
WBCs: 4200/mm3 2. About here diet will she take
Serum sodium: 129 3. Increase fluid in take
mEq/ml, serum 4. Provide high-calorie, low- or
potassium: 3.8 mEq/ml moderate-protein diet. Include
complex carbohydrates and fat
sources to meet caloric
needs (avoiding concentrated sugar
sources) and to
5. provide essential amino acids.
6. Restrict potassium, sodium,
and phosphorus intake, as
indicated

Students name: Rahma ebrahim mohamed