NURSING CARE PLAN

NCM 109 B
Patient’s data:
Name:
Rm no. and Bed no.:
Age:
Gender:
Religion:
Chief complaint:
Diagnosis:
Attending Physician:

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Review the Health • Nutrition • After 3 days of Independent: • Inflammation or • After 3 days
Assessment course ( imbalanced less nursing >Auscultate bowel irritation of the of nursing
book ) than body interventions, the sounds, noting intestine may be intervention
requirements client will be able absence or accompanied by s, the client
S>”verbalizes that related to nausea to maintain usual hyperactive sounds intestinal will be able
she is nauseated” as and vomiting. weight. hyperactivity, to maintain
verbalized by patient. diminished water usual
absorption and weight.
O> Hyperactive diarrhea.
bowel sounds Dependent
> Pale conjunctiva >Eliminate smells • Reduces gastric
and mucus from the stimulation and
membrane. environment. vomiting.
>V/S taken as
follows >Avoid foods that • Might increase
>T: 36.6 might cause or abdominal
>P: 98 exacerbate cramping
>R: 18 abdominal
BP: 110/90 cramping like
caffeinated
beverages,
chocolate, orange
juice.
>Measure • Provides
abdominal girth. quantitative
evidence of
changes in
gastric or
intestinal
distention.

>Observe skin or • Hypovolemia

mucous membrane fluid shifts and
dryness, and nutritional
turgor. Note deficits
peripheral edema contribute to
and sacral edema. poor skin
turgor,
edematous
tissue.

• Assess • Indicates return

abdomen of normal bowel
frequently for function and
return to ability to
softness, resume oral
appearance of intake.
normal bowel
sounds and
passage of
flatus.

• Weigh daily • Initial losses of

gains reflect
changes in
hydration.
Collaborative
>Monitor BUN, • Reflects organ
protein, function and
prealbumin or nutritional
albumin, glucose, status and
nitrogen balance as needs.
indicated.

> Advance diet as • Careful

tolerated. progression of
diet when
intake is
resumed risk of
gastric
irritation.