Assessment
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Nursing DX/Clinical Problem
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Client Goals/Desired Outcomes/Objectives
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Nursing Interventions/Actions/Orders and Rationale
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*I
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Evaluation
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Subjective
Pt demonstrates facial expressions of discomfort
Objective
Chart states that pt has not had a bowel movement
within 6 days
Chart states bowel sounds are hypoactive
Pt complaint of nausea
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Problem
Nausea
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Long Term:
Pt will verbalize knowledge of relief methods to reduce nausea by discharge.
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* 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).
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ü
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R/T
Constipation
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Short Term:
Pt will demonstrate relief of nausea by the end of this shift, by 1900
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*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).
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