Example of Nursing Care plan for Imbalanced nutrition: less than body requirements

Nursing Diagnosis:

Imbalanced nutrition: less than body requirements related to vomiting and loss of appetite as manifested by low protein level (47g/L).

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Assessment Cues:

Subjective data:

• “ I have loss of appetite ”
• “ I don’t want to take any food to avoid vomiting ”

Objective Data:

• Patient refuses to eat
• Decreased serum protein level = 48g/L
• Decreased K+ = 2.9 mEq/L

Planning and Outcome:

Short term:

• The patient will experience relief from nausea and vomiting in 2-4 hours

Long term:

• The patient will experience good appetite after two days of nursing interventions.

Nursing Interventions and Rationale:

NURSING INTERVENTIONS	RATIONALE
Independent:
– Assess and document amount, color, and characteristics of vomitus.	– Determine fluid replacement
– Eliminate smells from the environment	– Reduces gastric stimulation and vomiting response
– Monitor the BUN, protein, and glucose balance as indicated.	– Reflect organ function, nutritional status and needs
– Adjust diet according to nutritional needs and patient’s preferences	– Taking patient’s food preferences would help him gain a good appetite
Dependent:
– Administer antiemetic drugs	– Prevent loss of stomach contents

Evaluation:

Goal met:

• The patient’s nausea and vomiting stopped after administering antiemetics.
• The patient’s appetite has progressively improved.