NURSING CARE PLAN

S.No ASSESSMENT NURSING GOAL INTERVENTIONS IMPLEMENTATIONS RATIONALE EVALUATION

DIAGNOSIS
1. Subjective Data: Risk for deficient To  To check the fluid  Fluidvolume of the  It helps in further Fluid volume of
Patient says that he fluid volume maintain level of client by client is assessed & actions. client is
feels thirsty &has related to fluid maintains intake & intake charts are maintained up to
vomiting. prolonged & volume of output charts. maintained. some extent.
excessive client.
Objective Data: vomiting.  To encourage the  Client is encouraged to  It helps to increase
By checking intake client to take more take more fluid in her fluid volume of
& output chart fluids in her diet. diet. client.
 To maintain nothing
by mouth (N.P.O)  N.P.O status of the  Use to stop
status of client until client is maintained. vomiting or
committing has maintain nutritional
stopped. status is digestion
of nutrients.
 To administer  I.V. fluids are  I.V. fluids are
calorie agents (I.V. administered to client. administered to
Fluids) to client maintain fluid
until vomiting has volume.
stopped.

 Anti-emetic drugs are  Anti-emetic drugs

 To administer anti-
administered to client. are used to stop
emetic drugs as per
vomiting & prevent
 Doctor’s order. nausea.
2. Subjective Data: Imbalance To  To assess nutritional  Nutritional status of the  It helps in further Nutritional level
Patient says that she nutritional intake maintain intake of client by client is assessed. actions. of client is
feels hungry but less than body nutritional maintaining intake maintained up to
having vomiting. requirement status of output charts of some extent.
related to inability client. client daily.
Objective Data: to ingest or digest  To advise the client  Client is advised to  It helps to reduce
By checking intake nutrients. to restart oral intake restart oral intake when the inability of
& output charts. once emesis ceases emesis causes. digestion of
& appetite returns. nutrients.
 To prepare the diet
according to the  Diet is prepared  It increases the food
likes and dislikes of according to likes and intake of client.
client and serve in dislikes of client.
proper manner.
 It decreases reflux
 To instruct the  Client is instructed to of food.
client to remain in remain in upright
upright position for position for 45 minutes
45 minutes after after eating food.
eating.  Multi-vitamins drugs  It promotes the
 To administer multi are administered to nutritional status of
vitamins & folic client. the client.
acid tablets to client
as per doctor’s
order.
 Nutritional supplements  Nutritional
 To add nutritional are added in diet of supplements are
supplements in diet client. added to maintain
of client. nutritional status of
 client.
3. Subjective Data: Ineffective coping To  To access the  General condition &  It helps in further Coping
Patient says that she mechanism strengthen general condition & coping behavior of actions. mechanism is
have irritable mood related to stress of ing the coping behavior of client is assessed. strengthened up to
swing. pregnancy & coping client. some extent.
illness. mechanis
Objective Data: m of  To encourage the  Client is encouraged to  It helps to reduce
-Irritable mood client. client to verbalize verbalize her feelings fear & anxiety of
-by facial her feelings about about associated client & causes of
expression. pregnancy & stressor. anxiety if client.
associated stressor.

 To encourage the  Client is encouraged to  It helps to promote

client to participate participate in social coping behavior of
in social services services and counseling. client.
and counseling
services.

 To provide  Psychological support

is provided to client.  It helps to gain
psychological
confidence of
support to client.
client.
 Client’s family
 To encourage the members are  It helps to reduce
family members to encouraged to give fear & anxiety of
give sympathy to sympathy to client client.
client & talking talking with client in
with the client in free time.
free time.
4. Subjective Data: Knowledge deficit To  To assess the  Understanding level &  It helps in further Knowledge level
Patient says that she related to disease promote understanding level language of client is implementations. of client is
has no knowledge condition. knowledg and language of assessed. promoted up to
about her disease. e level of client. some extent.
client.  To teach the client  Client is taught about  It promotes
Objective Data: By about her nutrition. her nutritional needs. knowledge
asking questions to regarding nutrition.
client.  To teach the client  Client is taught about  It prevents
about importance of importance of fluid dehydration in
fluid intake. intake. client.

 To teach the client  Client is taught about  It promotes

about importance of importance of antenatal physical mobility of
antenatal exercises. exercises. client.
 To teach the client  Client is taught about  It increases
about common side common side effects of knowledge of client
effects of drugs. regarding
medications. medications.
 To teach the client  Client is taught about  It helps to know
about antenatal antenatal. about further
visits. complications &
growth &
development of
baby, health status
of mother &
effectiveness of
treatment.