Nursing Care Plan

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Medical Diagnoses: Nausea, Pain, Cholecystectomy

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

 

Pt complains “I can’t stop vomiting and I have felt nauseous all day long.”

 

Pt asks “Can you give me something for this nausea?”

 

 

Objective

     

Pt demonstrates grimaces with any movement

     

Cholecystectomy post op day 2

     

Pt experiences frequent vomiting episodes

     

Pt states pain is a 8 on a 10 point pain rating scale.


Problem

     

Nausea

Long Term:

 

Pt will verbalize knowledge of relief methods to reduce nausea and vomiting within one week.


* Educate the pt about the proper use of antiemetic medications to treat nausea.

     

Rationale:

Antiemetic medications can reduce the incidence of postoperative nausea and vomiting. (Ackley & Ladwig, 2008, p 563).

     

 

*Teach the pt the importance of oral care during episodes of nausea and vomiting.

 

Rationale:

“Oral care helps remove the taste and smell of vomitus, thus reducing the stimulus for further vomiting.” (Ackley & Ladwig, 2008, p 562).

 

 

 

     

X

Goal met. Pt verbalized understanding of nausea relief methods. Pt fully comprehends the teaching.

Continue interventions as listed. Continue to reinforce the importance of relief measures for nausea. Continue to educate the pt about antiemetic use and oral care during nausea episodes.

R/T

 

Pain

 

Cholecystectomy

 

 

Short Term:

 

Pt will demonstrate relief of nausea by the end of this shift.

*Provide distraction from nausea by using soft music or television per pt preference.

 

Rationale:

“Distraction can help direct attention away from the sensation of nausea.” (Ackley & Ladwig, 2008, p 562).

 

*Apply a cold wash cloth to the pt’s forehead.

 

 

Rationale:

“This is a distraction technique to help the client deal with nausea.” (Ackley & Ladwig, 2008, p 562).

 

 

*Provide a quiet, well-ventilated environment free of strong odors.

 

Rationale:

“Odors can cause or exacerbate nausea and vomiting.” (Ackley & Ladwig, 2008, p 562).

 

 

X

Goal met. Pt states she no longer feels nauseated. No further complaints of pain or nausea. Pt no longer demonstrates grimaces. Activity and movement is no longer affected by nausea.


Continue interventions as listed. Provide distractions for pt with music, television, and cold wash clothes. Continue to keep a well ventilated room that is free of odors. Continue to provide frequent oral care after vomiting.

AEB

 

Pt is experiencing vomiting episodes

 

Pt complains of a sick stomach and nausea

 

Post op day 2 of cholecystectomy

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References

 

Ackley, B.J., & Ladwig, G.B. (2008). Nursing diagnosis handbook: An evidence-based guide to planning care (8th ed.). St. Louis: Mosby Elsevier.



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