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ASSESSMENT NURSING BACKGROUND OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS KNOWLEDGE

Subjective: • Nutrition Nausea and After 3 days. Of Independent: After three days of
imbalanced less vomiting are not nursing •Auscultate bowel • Inflammation intervention, the
“Nagsusuka ako” than body diseases, but interventions, the sounds, noting or irritation of the client was able to
as verbalized by requirements rather are client will be able absence or intestine may be sustain a normal
patient. related to nausea symptoms of to maintain usual hyperactive accompanied by weight.
Objective: and vomiting. many different weight. sounds. intestinal
•Hyperactive conditions, such hyperactivity,
bowel sounds. as infection diminished water
•Pale conjunctiva ("stomach flu"), absorption and
and mucus food poisoning, diarrhea.
membrane. motion sickness,
•V/S taken as overeating, •Reduces gastric
follows: T: 36.6 P: blocked intestine, • Eliminate smells stimulation and
98 R: 18 Bp: illness, concussion from the vomiting
110/90 or brain injury, environment. response.
appendicitis, and
migraines. •Might increase
•Avoid foods that abdominal
might cause or cramping.
exacerbate
abdominal
cramping like
caffeinated
beverages,
chocolate, orange
juice. •Provides
quantitative
•Measure evidence of
abdominal girth. changes in gastric
or intestinal
distention.

•Observe skin or •Hypovolemia,


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

• Assess abdomen •Indicates return


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

•Weigh daily. •Initial losses or


gains reflect
changes in
hydration.

Collaborative:

• Monitor BUN,
protein, •Reflects organ
prealbumin or function and
albumin, glucose, nutritional status
nitrogen balance and needs.
as indicated.

•Advance diet as •Careful


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