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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 complains “I can’t stop vomiting and I have felt nauseous all day long.”
Pt asks “Can you give me something for this nausea?”
Objective
Pt demonstrates grimaces with any movement
Cholecystectomy post op day 2
Pt experiences frequent vomiting episodes
Pt states pain is a 8 on a 10 point pain rating
scale.
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Problem
Nausea
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Long Term:
Pt will verbalize knowledge of relief methods to reduce nausea and vomiting within
one week.
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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).
*Teach the pt the importance of oral care during episodes of nausea and vomiting.
Rationale:
“Oral care helps remove the taste and smell of vomitus, thus reducing the stimulus
for further vomiting.” (Ackley & Ladwig, 2008, p 562).
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X
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Goal met. Pt verbalized understanding of nausea
relief methods. Pt fully comprehends the teaching.
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Continue interventions as listed. Continue
to reinforce the importance of relief measures for nausea. Continue to educate the
pt about antiemetic use and oral care during nausea episodes.
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R/T
Pain
Cholecystectomy
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Short Term:
Pt will demonstrate relief of nausea by the end of this shift.
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*Provide distraction from nausea by using soft music or television per pt preference.
Rationale:
“Distraction can help direct attention away from the sensation of nausea.” (Ackley
& Ladwig, 2008, p 562).
*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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X
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Goal met. Pt states she no longer feels nauseated. No further complaints of pain
or nausea. Pt no longer demonstrates grimaces. Activity and movement is no longer
affected by nausea.
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Continue interventions as listed. Provide distractions for pt with music, television,
and cold wash clothes. Continue to keep a well ventilated room that is free of odors.
Continue to provide frequent oral care after vomiting.
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