help!making Nursing Care Plan (short term goal)

Whispera, MSN, RN · Dec 26, 2005

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

dekciwozzehs · Dec 26, 2005

Female

37

single

Date Started 12-10pm

Time in 9:00pm

excrtion 5

(Vomiting)

Body weaknes

short term goal

:confused:

Assessment?

Nursing Diagnosis?

Planning?

Intervention?

Evaluation?

thx for your reply :kiss

dekciwozzehs · Dec 26, 2005

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

Whispera, MSN, RN · Dec 26, 2005

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.

pvjerrys · Dec 26, 2005

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

soniblvn · Dec 26, 2005

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

RNin2007 · Dec 26, 2005

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

dekciwozzehs · Dec 26, 2005

thk you for your reply.

NANDA. Betty J. Ackley

Nursing Diagnosis: Nausea

Client Outcomes:

States relief of nausea

how?

dekciwozzehs · Dec 26, 2005

thx for your reply.

NANDA

Betty J. Ackley

Nursing Diagnosis: Nausea

States relief of nausea

methods can use to decrease nausea and vomiting

how?

Daytonite, BSN, RN · Dec 26, 2005

try this website http://www.rncentral.com/careplans/contents.html there is a nicely put together, simply stated care plan there for diarrhea. although there isn't one for vomiting, there is one for fluid volume deficit. suggest you do a general search of "vomiting" either in your textbooks or on the internet to find the many different ways of what causes it and how to treat it. find out as much as you can about vomiting, cause, effect on the body and treatment before you try to develop the written care plan for this patient. at this site http://www.ehendrick.org/healthy/index.htm you can find easily stated information on nausea and vomiting under the section on symptoms where a list of possible causes of vomiting is presented. this site http://www.fpnotebook.com/gi260.htm is more comprehensive as it is designed for doctors. it will give you a breakdown of the definitions of the various types of vomiting, the pathophysiology of it, causes, diagnostic tests to perform when assessing it's cause, management (based on the cause) and complications of vomiting. armed with that information you will be better able to anticipate what the doctor might order and what kind of complications to look for in order to develop a care plan and short term goal.