DEFINING NURSING SCIENTIFIC
PLAN OF CARE NURSING INTERVENTIONS RATIONALE
CHARACTERISTICS DIAGNOSIS ANALYSIS
SUBJECTIVE: SHORT TERM: INDEPENDENT 1. This fluid will provide or meet the
needs of the body’s acid-base
Patient came in for Fluid and electrolyte Hyperemesis After 4 hours of 1. Give parenteral fluids: electrolytes, balance, electrolytes and
elective request CS, imbalances related to gravidarum is thorough nursing glucose and vitamins according to hypoavitaminosis.
hypogastric pain excessive vomiting. characterized by intervention, the client program
mild-mod by 60 persistent nausea will be able to: 2. the provision of fluids
mins. by 60 and vomiting. 2. Monitor the provision of fluids and and electrolytes is a way to deal with
Radiating to the LSA a) reduce food in 24 hours as well persistent vomiting, this recording will
c̅ PS 1/10. No watery It may cause vomiting by as expenditures and recorded fluid be able to assess the balance
or bloody vaginal volume promoting an intake. of electrolytes are given, while the
discharge, (+) A7M depletion, electro environment number of how many calories can
lytes and acid- conducive for 3. Promote a well-ventilated
environment conducive for eating already be given.
base imbalances, doing ADL’s
nutritional b) improve skin 4. Change position frequently 3. to avoid the occurrence of vomiting.
OBJECTIVE: deficiencies, and turgor of the
even death. patient from 5. Examine the skin: the texture and 4.To promote proper circulation of
V/S taken as follows: blood, thus, preventing from fluid
poor to fair turgor.
- BP: 100/70 deficit.
mmHg 5.Dry skin and poor turgor is a sign of
- HR: 95 bpm LONG TERM:
COLLABORATIVE dehydration.
- RR: 18 cpm After 1 day of
- Temp: 36.4 thorough nursing 1. Administer medication
- O2 Sat: 98% intervention, the client (metoclopramide 1 ampule IVTT), as
- Weight: 135 ordered 1. To decrease the occurrence of
will be able to: vomiting
lbs.
a) Maintain body 2. Administer fluids and electrolytes
IE: 1 cm, 80 Eff, St (PNSS 1L with 40 meq KCl), as 2. To gradually correct the deficient in
fluid levels. fluid (hypertonic)
-5, IBOW, Cephalic b) Completely ordered.
A: G₂ P₁ (1001) PU Reference: eliminate the Reference:
38 ⁵/₈ weeks AOG, occurrence of
https://www.rnp vomiting. https://idoc.pub/documents/ncp-on-
CNIC, Prev. CS one Reference:
edia.com/nursing c) Increase serum electrolyte-imbalance-vyly0yz58vnm
for CPD (2014 CHH) https://www.rnpedia.com/nursing-
-notes/maternal- Na+ level from
Admit and-child- notes/maternal-and-child-nursing-
nursing- notes/hyperemesis-gravidarum
notes/hyperemes
is-gravidarum
DEFINING NURSING SCIENTIFIC
PLAN OF CARE NURSING INTERVENTIONS RATIONALE
CHARACTERISTICS DIAGNOSIS ANALYSIS
SUBJECTIVE: SHORT TERM: INDEPENDENT 1. Maintaining a fluid electrolyte
balance and prevent further vomiting.
Imbalanced Nutrition: Hyperemesis After 2-3 hours of 1. Restrict oral intake until the
Less than body gravidarum is nursing intervention, vomiting stops 2.Can adequate intake of nutrients
“I feel nauseous and requirements related characterized by the patient will be able your body needs of electrolytes are
I keep on vomiting, to the frequency of persistent nausea to: 2. Encourage to eat small meals but given, while the number of how many
on top of that I really excessive vomiting and vomiting. often calories can already be given.
don’t have any a) Verbalize
appetite” as It may cause understanding 3. Advise to avoid fatty foods 3. Fatty foods can stimulate nausea
verbalized by the volume of individual 4. Encourage to eat a snack such as and vomiting.
patient. depletion, electro dietary and crackers, bread and tea (hot) warm
lytes and acid- fluid restriction. 4. A snack can reduce or prevent
before waking up at noon and before nausea, vomiting, excessive
base imbalances, bed
nutritional LONG TERM: excitatory.
OBJECTIVE:
deficiencies, and After 1 week of 5. Malnutrition mother affects fetal
-Excessive vomiting even death. nursing intervention, growth and aggravate the decrease in
5. Measure uterine enlargement.
-Weight loss (5-10 the client will be able the complement of brain cells in the
kg) to: fetus, resulting in deterioration of fetal
development and the possibilities
- Breath smelled of b) Demonstrate further.
acetone stabilized
weight or gain COLLABORATIVE
- Dry skin, mucous toward usual/ 1. Administer anti-emetic drugs
membranes dry lips desired range 1. Preventing vomiting and maintain
prescribed, as ordered fluid and electrolyte balance.
with normal
-Sunken eyes and laboratory 2. Collaborate with interdisciplinary
dry tongue. 2. To set nutritional goals when client
values. team. has specific dietary needs,
Reference:
-Restlessness malnutrition is profound, or long-term
https://www.rnp feeding problems exist.
-BP: 100/80 mmHg edia.com/nursing Reference:
-notes/maternal- Reference:
-T: 36.3
and-child- https://www.rnpedia.com/nursing-
notes/maternal-and-child-nursing- https://idoc.pub/documents/ncp-on-
-PR: 110 bpm nursing- electrolyte-imbalance-vyly0yz58vnm
notes/hyperemes notes/hyperemesis-gravidarum
-RR: 17 cpm is-gravidarum
