Nursing Careplan

ASSESSMENT
Subjective Data Objective Data Clients Diagnosis/Problem Plan, including Goals/Client Outcomes

1.Every time I drink or eat I vomit 2.I have heartburn 3. : I refuse to take my Ibuprofen by mouth because I will vomit

1.TPN @ 50ml/hr 2. Lipids @ 25ml/ht 3.Dr. ordered labs CMP, Phosphorus, 4.Output less than 30 ml/hr 5. Pt eating/drinking less than 15% of full liquid diet 6. After drinking juices pt vomited green emesis.

Imbalanced Nutrition: less than body requirements r/t intolerance of PO fluid diet AEB nausea and vomiting

Short term goals: 1.Pt will eat cup of applesauce for lunch without vomiting 2. Pt will intake 32 oz of water in small increments by 1500 Long term goals: 1.Pt will recognize factors contributing to underweight within 48 hrs 2. Pt will Identify nutritional requirements by within 24 hrs

Nursing Interventions and Actions

1.Monitor for signs of malnutrition including: brittle hair that is easily plucked, bruises, dry skin, pale skin and conjunctiva, muscle wasting, smooth red tongue, disorientation / Morning assessment indicated hair soft, no bruises, skin moist and pink, no muscle wasting, tongue pink and smooth, pt alert X 3 2.Note laboratory test results: serum albumin serum total protein, serum ferritin, transferring, hemoglobin, hematocrit, and electrolytes / Albumin(2.9), BUN (7.8), Phosphorus ( 1.5), Potassium ( 2.6), Chloride (96), Direct LDL (56) 3. Determine healthy body weight for age and height. Refer to dietician for complete nutrition assessment if 10% under healthy body weight or if rapidly losing weight / BMI 16.3 (weight 101 lb height 55) 4.Monitor food intake; record percentages of served food (25%, 50%) ;Observe patients ability to eat (time involved. Motor skills, visual activity, and ability to swallow. / Pt eating little food, less than 10% during course because of pain and nausea ; Pt able to eat independently with no problems 5.Ambulate pt three times a day / Pt was able to ambulate from bed to chair three times before 1700; Pt also walked up the hallway and back

Rationale for Interventions [cite your source(s)] 1.Decreased levels of nutrition causes a decrease in the nutrients supplied to the body parts which aid in healthiness. Ackley, B.J. &
Ladwig, G.B. , 2010, pg. 353

2.A serum albumin level of less than 3.5 is considered an indicator of risk or poor nutritional status. Ackley,
B.J. & Ladwig, G.B. , 2010, pg. 353

Goal Met ___Goal Not Met X Evaluate Goals/Interv. If not met Short term goal 1.Goal Met Pt ate 4 oz cup of applesauce at 1230 for lunch without feeling nausea or vomiting. 2. Goal Met Pt was able to drink 32 oz 48 oz of water without nausea or vomiting by 1600. Long term goal 1.Goal not met because patient was in pain from abdominal incision and did not want to discuss nothing other than when she would receive her next pain med. 2. Goal not met because patient was in pain from abdominal incision and did not want to discuss nothing other than when she would receive her next pain med

3.In the developed world , protein-calorie malnutrition most often accompanies a disease process. Ackley, B.J.
& Ladwig, G.B. , 2010, pg. 353

4.Patients are susceptible to protein-calorie malnutrition when they are unable to feed themselves. Ackley, B.J.
& Ladwig, G.B. , 2010, pg. 353

5.Immobility leads to negative nitrogen balance that fosters anorexia Ackley,

B.J. & Ladwig, G.B. , 2010, pg. 353

Reference Ackley, B.J.,Ladwig, G.B., (2010) Nursing Diagnosis. St. Louis: MOSBY.