Need someone to correct my careplan

nursing diagnosis

high risk for nutritional imbalance due to vomiting.

goal. within 30 days 2/28/09

• patient will maintain fluid volume and sustain optimum levels of nutrition. - you have no nursing interventions that address how you will maintain her fluid volume or make sure she is eating enough food; nor do you address how anyone can assess she is eating enough.
  
• client will learn and understand the importance of nutrition. - you have no teaching interventions that explain anything to the patient about nutrition or how important it is for her. vomiting is first a safety issue.
  
• client will keep to a daily active routine after meals - how will you accomplish this?
  
• client will maintain normal nutritional levels. - what are normal nutritional levels for her? you have no interventions that assess this for this patient or state how it will be monitored, so how can normal levels be maintained if they are not even defined?
  

nursing intervention

advise the client against going to bed after eating or drinking and explain and teach client the ramifications of imbalanced nutrition due to vomiting. - for a patient of limited cognitive ability i wouldn't advise, but make an order of the staff that she not be allowed to go to bed. vomiting is a safety issue and she could aspirate, choke and die.

provide a task or activity to occupy client after meals in order to lengthen time spent out of bed to prevent vomiting. - for a patient of limited cognitive ability i would specify the tasks or activities in this care plan.

patients with gerd should not be receiving any acid or foods with high fat content.

eating 2-4 hours before sleeping is an absolute no-no with these patients so her lying down after eating dinner needs to be stopped or her meals need to be adjusted with main meal at lunch and the evening meal being very small if the patient is unwilling or uncooperative in following a plan of care.

head of bed should be elevated or blocks should be placed under the head of her bed.

this patient has gerd, gastroesophagitis and gastritis. is she on medication for this? i would have an intervention that mentions that her medications be given as ordered.

rationale

client will have better understanding of how to maintain balance of nutrition. - this is not a rationale. a rationale is why you are doing something. the reason for teaching the patient why she needs to remain upright after eating is so the food has a chance to move on down her gi track and be fully digested.

client will be too occupied (diverted by) with activities or tasks to keep her from going to bed so early after eating.

outcome/evaluation

client understand the importance of nutrition.

met.

client is able to complete activities or tasks after meals.

met

client maintains normal nutritional levels.

met

a "risk for" problem means the situation (in this case, not getting enough nutrients) doesn't exit yet. with "risk for" problems the interventions need to be:

• strategies to prevent the problem from happening in the first place
  
• monitoring for the specific signs and symptoms of this problem
  
• reporting any symptoms that do occur to the doctor or other concerned professional
  

i thought a great deal about your post and care plan last evening. i think your diagnosis is wrong. there is a very definite and real problem here as opposed to an anticipated problem. this patient lies down too early in the evening after eating and she vomits putting herself at risk of aspirating and choking. i don't think nutrition is the major issue unless there is more information that you haven't disclosed. i can't think of any writing or research that would support vomiting an entire meal daily resulting in malnutrition unless it happens nightly and over a long period of time. people who are anorexic will loose weight because they deliberately vomit to empty their stomachs of all the food they eat regularly, but that is not the case here unless you haven't described this problem clearly. this patient compensates for her food loss by getting food from other sources. do you have evidence that she is losing weight because of this vomiting? i think your rationale of this is faulty. i'm more concerned about her breathing safety. gerd patients are told to stay upright for 2-4 hours after a full meal. this patient isn't cognitively able to comply with that because of her mental retardation. so, the nursing staff needs to step in. the nursing staff can "advise" her to wait after she eats all they want, but the patient obviously isn't going to do that, has demonstrated that, and other strategies need to be sought. this is a real problem and not an anticipated one as you are trying to make it. there are a number of ways this can be diagnosed. her cerebral palsy makes choking on her vomitus a real safety issue since her muscular tone is compromised. the fact that she doesn't speak indicates that she has muscular deficits in the mouth and throat. so, risk for aspiration is one way to go. however, i, personally, would diagnose ineffective health maintenance r/t cognitive impairment, inability to make appropriate judgments and unwillingness to follow instructions aeb consistently retiring to bed immediately after eating dinner resulting in the vomiting of the meal, not complying with the dietary plan of her physician and obtaining food insistent with her diet plan to eat elsewhere. you know what really bothers me about this? she's in a wheelchair, can't talk and depends on others. people are enabling her to some extent!

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