Nursing Care Plan

Name: Joshua S. Pascasio

Date:
Section:
Patient:
Assessment Nursing Planning Intervention Rationale Evaluation
Diagnosis
Subjective Cues: Risk for Goal: >Identify factors >Choice of After doing the
imbalanced After the nursing that are interventions necessary
Objective cues: nutrition: less intervention the contributing to depends on the nursing
than body client will nausea or underlying cause interventions and
requirements maintain desired vomiting: copious of the problem. teachings, the
related to body weight. sputum, aerosol client:
Increased treatments,
metabolic needs severe dyspnea, > maintained
secondary to and pain. desired body
fever and > Eliminates weight.
infectious > Provide noxious sights,
process covered tastes, smells from
container for the patient
sputum and environment and
remove at can reduce
frequent nausea.
intervals. Assist
and encourage > Restlessness,
oral hygiene after irritation,
emesis, after confusion, and
aerosol and somnolence may
postural drainage reflect hypoxemia
treatments, and and decreased
before meals. cerebral
oxygenation.

>Reduces effects
>Schedule of nausea
 Nursing Care Plan
Name: Joshua S. Pascasio
Date:
Section:
Patient:
respiratory associated with
treatments at these treatments.
least 1 hr before
meals.

>To replenish lost

>Maintain nutrients.
adequate
nutrition to offset
hypermetabolic
state secondary
to infection. Ask
the dietary
department to
provide a high-
calorie, high-
protein diet
consisting of soft, >Milk products
easy-to-eat may increase
foods. sputum
production.
>Consider
limiting use of
milk products
> Maintain bed
rest. Encourage
 Nursing Care Plan
Name: Joshua S. Pascasio
Date:
Section:
Patient:
use of relaxation > To
techniques and prevent aspiration.
diversional Note: Dont give
activities. large volumes at
one time; this
>Elevate the could cause
patients head vomiting. Keep the
and neck, and patients head
check for tubes elevated for at
position during least 30 minutes
NG tube after feeding.
feedings. Check for residual
formula regular
intervals.

>Bowel sounds
may be
diminished if the
infectious process
is
>Auscultate for severe. Abdominal
bowel sounds. distension may
Observe for occur as a result
abdominal of air swallowing
distension. or reflect the
influence of
bacterial toxins on
the
gastrointestinal
 Nursing Care Plan
Name: Joshua S. Pascasio
Date:
Section:
Patient:
(GI) tract.

> These measures

>Provide small, may enhance
frequent meals, intake even
including dry though appetite
foods (toast, may be slow to
crackers) and/or return.
foods that are
appealing to
patient.
Presence of
>Evaluate chronic conditions
general (COPD or
nutritional state, alcoholism) or
obtain baseline financial
weight. limitations can
contribute to
malnutrition,
lowered resistance
to infection,
and/or delayed
response to
therapy.