NURSING CARE PLAN

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EXPECTED

EXPLANATION OUTCOMES
S> “I experience Imbalanced Nausea and After 2 days of 1. Assess After 2 days of
vomiting Nutrition less vomiting are nursing client’s - Identifies nursing
whenever I than body common side intervention, experiences. client’s interventions,
undergo requirements effects of the client will concerns, the client will: -
chemotheraphy.” related to chemotherapy identify misinformation - identify
nausea and interventions and strategies previously
O>hyperactive vomiting for nausea for used
bowel sounds and vomiting intervention. successful
>pale and will report 2. Auscultate interventions
conjunctiva and decrease in bowel sounds, - Irritation of for nausea
mucous incidence of noting absence the intestine and vomiting
membrane nausea and or hyperactive may be - report
vomiting. sounds. accompanied decrease in
by intestinal incidence of
hyperactivity, nausea and
diminished vomiting
water
absorption and
diarrhea.
3. Eliminate
smells from the - Reduces
environment. gastric
stimulation and
vomiting
response.
.
4. Adjust diet
before and after - Clients
drug respond
administration differently to
according to the food after
client’s chemotherapy.
tolerance.
Provide diet
containing foods
that relieve the
client’s nausea
and vomiting.

5. Provide client
non- - Reduces
pharmacologic anxiety which
therapies like can contribute
music therapy, to nausea and
biofeedback, vomiting.
and guided
imagery before
and after
chemotherapy.

6. Ensure
adequate fluid - Adequate
hydration. fluid volume
dilutes drug
 levels,
decreasing
stimulation of
vomiting
7. Monitor the receptors.
BUN, protein,
pre albumin or - Reflect organ
albumin and function and
glucose, nutritional
nitrogen balance status and
as indicated. needs.

8. Communicate
with the
dietician. - Careful
progression of
diet when
intake is
resumed
reduces risk of
9. Administer gastric
prescribed irritation.
antiemetics,
sedatives and
corticosteroids - Limits the
before adverse
chemotherapy. experience
and facilitates
control.