1. Nursing Diagnosis: Risk for Fluid Volume Deficit related to inadequate intake and excessive fluid output (nausea and vomiting)
Goal:
After nursing actions, adequate fluid intake.
Expected outcomes are:
- The mucosa of the lips moist
- Good skin turgor
- Good capillary refill
- Input and output balanced
- Fill your individual needs. Encourage clients to drink.
- Provide additional IV fluids as indicated.
- Monitor vital signs, evaluation of skin turgor, capillary refill and mucous membranes.
- Collaboration: the provision of drugs.
- Adequate fluid intake will reduce the risk of patient dehydration.
- Replacing lost fluids and improve fluid balance in the immediate phase.
- Indicate the status of dehydration or the possibility of the need to increase fluid replacement.
- Provision of drugs serves to inhibit gastric acid secretion.
Goal:
After the act of nursing, pain can be reduced, patients can rest and generally good condition.
Expected outcomes are:
- Clients express the pain diminished or disappeared.
- The client does not grimace in pain.
- Vital signs are within normal limits.
- The pain intensity was reduced (reduced pain scale 1-10).
- Demonstrate relax, rest, sleep, increased activity quickly.
- Investigate complaints of pain, note the location, intensity of pain, and pain scale.
- Instruct patient to report pain as soon as it began.
- Monitor vital signs.
- Explain the causes and effects of pain on the client and his family.
- Encourage rest during the acute phase.
- Encourage relaxation techniques.
- Provide an environment conducive situation.
- Collaboration with the medical team in the delivery of the action.
- To find out where the pain and facilitate interventions to be performed.
- Early intervention to facilitate recovery of muscle control pain by decreasing muscle tension.
- Autonomic responses include, changes in blood pressure, pulse, respiration, associated with pain relief.
- With the causes and consequences of pain the client is expected to participate in treatment to reduce pain.
- Reduce pain that was exacerbated by movement.
- Decrease muscle tension, increase relaxation, and increased sense of control and coping abilities.
- Provide support (physical, emotional, increased sense of control, and coping skills).
- Eliminate or reduce the client's complaints of pain.
3. Nursing Diagnosis : Imbalanced Nutrition: Less Than Body Requirements related to the lack of food intake.
Goal:
After the patient's nutritional needs of nursing actions are met.
Expected outcomes are:
- General condition is quite
- Good skin turgor
- Increased weight
- Difficulty swallowing is reduced
- Instruct patient to eat small meals but frequently.
- Give soft foods.
- Perform oral hygiene.
- Measure weight basis.
- Texture observation, the patient's skin turgor.
- Observations of nutritional intake and output.
- Keeping the patient remained stable nutritional prevent nausea and vomiting.
- To facilitate the patient to swallow.
- Oral hygiene can stimulate the appetite of the patient.
- Knowing the development of nutritional status of patients.
- Knowing a patient's nutritional status.
- Knowing a patient's nutritional balance.