Cough NCP

DAVAO DOCTORS COLLEGE
Gen. Malvar St., Davao City GRADE:

Nursing Program
NURSING CARE PLAN
Name of Patient: Patient H.P. Date of Admission: January 13, 2021 Room: 305
Age: 21 years old Sex: Male Civil Status: Single Chief Complaint: Nausea
Religion: Roman Catholic Attending Physician: Dr. Hermione Granger, IM
PROBLEM SCIENTIFIC BASIS GOAL/OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

January 13, 2021; Nausea related to After 8 hours span of 1. Administer the Taking the prescribed medications January 13, 2021;
1:00PM treatment regimen as care, the patient will prescribed to prevent nausea and vomiting 9:00PM
manifested by patient be able to report medications per caused by certain medical
Subjective: “Ma’am, reporting feeling nauseous decreased severity of doctor’s order. treatments will reduce episodes of “GOAL MET”
bag-o ra ko nag sugod and admitting to his first nausea as manifested nausea.
og HIV treatment, pero by: After 8 hours span of
HIV treatment.
karon lain naman 2. Provide a basin within Since nausea is associated with care, the patient was
hinuon kaayo akong a. Patient’s easy reach of the vomiting, patient should have easy able to report
gibati. Ika-tulo nako Basis: Nausea is a tolerance of patient. access to a basin. This way, the decreased severity of
nag suka, ug kasukahon subjective phenomenon of clear liquids patient is relieved of the discomfort nausea as manifested
ra gihapon ko hangtod an unpleasant feeling in the within 8 hours from having to go to the restroom. by:
karon”, as verbalized by back of the throat and without nausea Abrupt movements could worsen
the patient. stomach, which may or and vomiting. the condition. a. Patient’s
Objective: may not result in vomiting. b. Patient could tolerance of
Nausea and vomiting are eat appropriate 3. Provide clear liquids Providing clear liquids is essential to clear liquids a
• Patient’s face is two of the most common food in the when nausea is under maintain the patient’s fluid balance. within 8 hours
pale and his skin symptoms experienced by absence of control within 6 hours. without
is cold and those with HIV, however nausea and nausea and
clammy. these are most commonly vomiting. 4. Give small, An empty stomach exacerbated by vomiting.
• Increased attributed to medication c. Patient’s appropriate food (dry, vomiting could intensify nausea. b. Patient could
swallowing of side effects. Medications verbalization of bland, low-fat) to the Giving the patient small amount of eat
patient is can influence food intake certain type of patient. food to eat will help conserve appropriate
observed. by producing side effects foods that may nutritional status. food in the
• Sweating and such as nausea, vomiting, aggravate absence of
build-up of nausea.
Name: Shekinah C. Poliquit, BSN 11E Clinical Instructor: Sir Paul Andre Lumiguid
saliva are decreased appetite, and d. Patient’s 5. Get rid of possible Noxious fumes or strong odors nausea and
evident. changes in sensorium. verbalization in triggers for nausea could overwhelm the patient. vomiting.
• Patient is knowing the such as strong odors; c. Patient’s
noticeably weak possible side the room where the verbalization
References:
and was seen effects of HIV patient is should be of certain type
Hinkle, J., & Cheever, K.
holding arms treatment and well ventilated. of foods that
(2013). Brunner and
around the how to may aggravate
Suddarth’s textbook of
stomach in manage them. 6. Assess the patient’s This is to determine the patient’s nausea.
medical-surgical nursing
discomfort. e. Vital signs nausea every 2-3 response to the efficacy of the d. Patient’s
(13th ed.). Wolters Kluwer
• Vital signs: within normal hours. medications and interventions done verbalization in
Temp: 37.9°C range. to alleviate the condition. knowing the
NANDA International,
RR: 20 cpm possible side
Nursing Diagnoses,
HR: 104 bpm, 7. Educate the patient High-fat foods, foods with strong effects of HIV
definitions and
BP: 120/80 about certain type of odor, spicy food and foods that the Treatment and
classifications 2018-2020
O2 saturation: foods that could patient are allergic to could intensify how to
(11th ed.).
96% aggravate nausea. for nausea. manage them.
Chubineh S, McGowan J. e. Vital signs
Nausea and vomiting in 8. Educate the patient People who undergo medical within normal
HIV: a symptom review. the patient about the treatments such as chemotherapy, range.
Int J STD AIDS. 2008 side effects of HIV surgery, HIV treatments and other Temp: 36.5°C
Nov;19(11):723-8. doi: Treatment and the medical regimen are likely to RR: 16 cpm
10.1258/ijsa.2008.008244. ways of managing experience side effects. Helping the HR: 95 bpm,
PMID: 18931263. them. patient understand that this part of BP: 120/80
the healing process is normal and O2 saturation:
that help is available may give him 96%
the clarity on how to manage these
side effects.
Name: Shekinah C. Poliquit, BSN 11E Clinical Instructor: Sir Paul Andre Lumiguid

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DAVAO DOCTORS COLLEGE

Gen. Malvar St., Davao City GRADE:

PROBLEM SCIENTIFIC BASIS GOAL/OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

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