Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective client expressed a lack of interest in food because of nausea

Objective

Increased metablic need due to illness

Vomited all meds

Vomiting after meals

Eating less than 50% of meals

Problem

Imbalanced nutrition: less than body requirements

Long Term:

1. client will not experience weight loss during her stay           

1. obtain and record patient’s weight at same time every day

1. to obtain most accurate readings

*

Client did not experience any weight loss during stay

R/T

Inability to ingest foods secondary to nausea

Short Term:

1.client will consume at least 75% of food at mealtimes

1.remove cover of food tray before bringing it into the room

1. sudden concentrated food odors that comes when the cover is removed can trigger nausea

2.provide distraction from the sensation of nausea, using soft music, television, and videos per the client preference.

2. distraction can help direct attention away form from the sensation of nasea

*

Client is able to consume adequate nutrition of at least 75% of food at mealtimes  

AEB

Vomiting after meals