Assessment Subjective: (none) Objectives: The patient manifested the following: Vomiting

Nursing Diagnosis Risk for Deficient Fluid Volume

Objectives Short Term: After 3-4 hours of nursing interventions, the patient will participate in activities that reduce the occurance of vomiting.

Nursing Interventions Monitor intake and output.

Rationale Provides information about replacement needs and organ function. Prolonged vomiting, gastric aspiration and restricted oral intake can lead to deficits in sodium, potassium and chloride.

Expected Outcome Short Term: After nursing interventions, the patient shall have participated in activities that reduce the workload of the heart. Long Term: After 2-3 days of nursing interventions, the patient shall have been able to display hemodynamic stability.

Monitor for signs of increased or continued nausea/vomiting, abdominal cramps, weakeness, twitching, seizures, irregular heart rate, paraesthesia, hypoactive or absent bowel sounds, depressed respirations. Eliminate noxious Long Term: sights/smells from After 2-3 environment. days of Monitor Vital signs. nursing Assess mucous interventions, membranes, skin turgor, the patient peripheral pulses and will be able to capillary refill. display Observe for signs of adequate bleeding. fulid balance as evidenced by stable vital Use small gauge signs, moist needles for injections, mucous apply firm pressure for membranes, longer than usual after good skin venipuncture turgor/ Have client use soft capillary refill toothbrush or cotton/wash and adequate swabs and alcohol free urine output.

Reduces stimulation of vomiting center. Indicators of adequacy of circulating volume/ perfusion. Prothrombin is reduced and coagulation time prolonged when bile flow is obstructed, increasing risk of bleeding or hemorrhage. Reduces trauma, risk of bleeding or hematoma formation. Avoids trauma and bleeding of gums. Alcohol can be drying and cause irritation.

Decreases GI secretions and hypermotility.

mouth wash instead of a toothbrush if bleeding is a problem Keep client on NPO as necessary. Insert NG tube and maintain patency as indicated. Administer Antiemetics. Monitor lab studies; e.g., Hb/Hct, electrolytes, prothrombin level/clotting time. Administer IV fluids, blood products, as indicated

Provides rest for GI tract and relief of vomiting. Helpful in reducing nausea and vomiting. Provides information on circulating volume, electrolyte balance, and adequacy of clotting factors. Maintain adequate circulating volume and aid in replacement of clotting factors.