care plan for nutrition

1. Assessment

1.1. objective data

1.1.1. . Physical examination revealed temperature :36.1, BP: 110/80 mm Hg, P:86 b/min, RR: 14 b/min.

1.1.2. Abdominal physical exam showed soft abdomen, hyperactive bowel sounds and tenderness on

1.1.3. Weight: 40 kg Height: 160 cm. Laboratory investigations: WBC:13,000 Creatine: 0.6 mg/dl Hb: 13.3mg/dl

1.2. subjective data

1.2.1. complaining of vomiting

1.2.2. Two days before admission, she ate heavy spicy meal in restaurant then started to vomit the ingested food for 20 minutes

2. Implmenting

2.1. Measure client weight.

2.2. Monitor and record the number of vomiting

2.3. Monitor the client’s food intake.

2.4. Provide a diverse diet according to his needs.

2.5. Provide parenteral fluids, as ordered.

2.6. Refer to a dietitian if indicated.

3. Evaluatin

3.1. Control of diarrhea.

3.2. Minimize the risk for infection.

3.3. Improve hydration and nutritional intake.

3.4. Eliminate the risk of infection transmissionF

4. Diagnosis

4.1. Risk for infection related to inadequate secondary defenses or insufficient knowledge to avoid exposure to pathogen

4.2. Impaired skin integrity related to constant presence of diarrheal stools.

4.3. Deficient fluid volume related to diarrheal stools

4.4. Imbalanced nutrition: less than body requirements related to malabsorption of nutrients

5. planning

5.1. Control of diarrhea.

5.2. Minimize the risk for infection.

5.3. Improve hydration and nutritional intake.

5.4. Eliminate the risk of infection transmissionF