help!making Nursing Care Plan (short term goal)

You need to give us more information! Also, you should have a few examples of careplans in your textbooks that would work, I think.

Female

37

single

Date Started 12-10pm

Time in 9:00pm

excrtion 5

(Vomiting)

Body weaknes

short term goal

Assessment?

Nursing Diagnosis?

Planning?

Intervention?

Evaluation?

thx for your reply :kiss

example.

Assessment =Diarrhea for 3 weeks>Distended abdomenFamily history of stomach cancer

Diagnosis =Vomiting result from activation of the vomiting reflex primary by irritation of the stomach and small intestine. Based on the Anatomy and Physiology Vomiting is cause of bacterial infection of the bowel, increase fluids and ion loss.

Planning =Maintain or restore normal bowel elimination pattern.Maintain or regain normal stool.

Implementation =1. Drink at least 8 glasses of water per day to prevent dehydration2. Ingest food with sodium and potassium like meats, vegetables and fruits “tomatoes, potatoes, banana, peaches”

Evaluation =Normal bowel elimination pattern1(one)’s a dayRegain normal stool Weight is 185 lbs

Do you have a book that lists nursing diagnoses? Vomiting isn't a nursing diagnosis. One that would work is: risk for altered nutrition: less than body requirements related to vomiting.

Short term goals are very basic, and something that can be accomplished quickly, such as: patient will experience a decrease in vomiting within 24 hours.

Another Nsg Dx: Fluid Volume Deficit r/t dehydration as manifested by diarrhea x3 weeks and vomiting.

Short term goal: Pt will have balanced intake and output in 24 - 48 hours.

Implementation: Monitor amount, frequency & color of fluid loss.

Assess for postural hypotension.

Monitor hydration status (eg moist mucous membranes, adequacy of pulses and orthostastic blood pressure_

Weigh daily and monitor trends

Maintain accurate intake and output record.

Offer 280ml/hr as tolerated, if not contraindicated.

Evaluation: Pt has achieved balanced intake = output. or Pt has not achieved balanced I&O (Continues to have intake

Maybe I don't understand your question completely, (sorry) What type of patient do you have? Diagnosis, problems etc.... I need more info.

Risk for Deficient Fluid Volume

Assess causitive/contributing factors.

Note LOC/mentation.

Assess other etiologic factors present (e.g., availability of fluids, mobility, presence of fever).

To prevent occurence of fluid volume deficit, weigh client and compare w/recent weight history.

Maximize fluid intake (specific client preference), and assess skin turgor/oral mucous membranes.

Review labs (hb/hct, lytes, BUN/Cr).

...hope this gets you going in the right direction.

~J

thk you for your reply.

NANDA. Betty J. Ackley

Nursing Diagnosis: Nausea

Client Outcomes:

States relief of nausea

how?

thx for your reply.

NANDA

Betty J. Ackley

Nursing Diagnosis: Nausea

States relief of nausea

methods can use to decrease nausea and vomiting

how?