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NURSING PROBLEM: NAUSEA AND VOMITTING ASSESSMENT

Subjective: Medyo nahihilo ako at di makakain ng maayos dahil napapasuka ako pag napasobra as verbalized by the patient Objective: 1. Vomitting after eating 2. Dizziness upon standing 3. Slight dehydration upon skin turgor test 4. Increased RR after episodes of vomiting 5. V/s as follows: BP: 130/110 RR: 22 Temp: 37.1 PR: 88

NURSING DIAGNOSIS
Nausea related to hypertensive and antibiotic agent or manifested of aversion towards food and increased gagging sensation.

PLANNING

IMPLEMENTATION

RATIONALE

EVALUATION

Short term: After 3 hours of nursing intervention the patient will: 1. Be free or will have decrease nausea 2. Have a decreased episode of vomiting. Long term: After 2 days of nursing intervention the patient will: 1. Manage chronic nausea as evidence by acceptable level of dietary intake. 2. Maintain and regain

1. Assess GI tract

2. Identify situations the client perceived as nauseatic situation. 3. Promote comfort and enhance intake. 4. Encouraged dry foods and ice chips during episodes of nausea. 5. Advise to drink fluid 30 min before or 30mins after the meal instead with meal. 6. Provide bland diet if it is not indicated. 7. Avoid dairy products, increased sweet, fried or fatty foods, gas-

1. To ensure that there is no problem that will cause vomiting. 2. To decreased the possibility of nausea episodes upon meals. 3. Increased nutrients intake. 4. Dry and ice chips have natural tendencies to decrease nausea. 5. Fluids stimulate increased gastric secretion thereby increasing the chance of vomiting. 6. Decrease gastric acidity and increased nutrients intake. 7. The foods mentioned increases the possibility of

After the nursing intervention the patient was: 1. Been freed or decreased nausea sensation 2. Had decreased episodes of vomiting. 3. Able to take acceptable level of dietary intake.

weight as appropriate

forming vegetable. 8. Encouraged to eat in frequent small meals through the day instead of 3 full meals 9. Frequent oral care 10. Administer anti emetics to deter side effect of medications. 11. Suggest wearing loose clothes

nausea. 8. Big meals put too much pressure in the stomach and stimulating gastric acidity. 9. Decrease bad taste 10. To decrease the side effect of some medications 11. Decreasing pressure on the abdomen to allow good intake of foods. 12. Chewing allows the food to be degenerated before ingestion.

12. Encouraged to eat food slowly.

13. Monitor v/s 14. Monitor I & O.

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