My first care plan!

[katknits]

Hi everyone, this is my first post so I hope that I'm posting this question in the correct forum. I started my first year of an ADN program on Monday and today I am writing my first care plan. I feel like I have no idea what I am doing so I would appreciate it if anyone could provide feedback. I used NANDA, NIC, and NOC. I tried to write my own nursing diagnosis but I feel unsure about the wording I used. I also tried to use the SMART method of goal setting so if my goals are not specific, measurable, attainable, realistic, or timed, please let me know. I left the evaluation section blank because obviously I don't have that information. I know I'm asking for a lot of feedback but this is my first attempt at a care plan and I've only been in school for a week. I appreciate ALL feedback! Thank you :)

Here's my case:

52 year old female came into the hospital with reports of abdominal pain. She was diagnosed with a small bowel obstruction and underwent a laparoscopic colectomy. Two days after surgery, she reports nausea and the inability to eat and keep down liquids.

And here's my care plan:

Nursing Diagnosis:

Nausea related to surgery as evidenced by patient reported feeling nauseous.

Risk for imbalanced nutrition related to inability to eat and keep down liquids.

Goals:

Client will state relief of nausea by 1800 August 26

Client will consume 80% of all meals by 1800 August 26

Client will increase activity by walking 10 feet, 3 times per day

Interventions:

RN will assess nausea and pain level

RN will administer anti-emetics and analgesics as ordered

RN will record food and fluid intake

RN will work with client to increase mobility

Evaluation