CUES NURSINGDIAGNOSISSCIENTIFICBASISGOAL & OUTCOMECRITERIA NURSINGACTIONS & NURSINGORDERSRATIONALE OF NURSINGORDERSEVALUATION
S-³Pirme lang gamayakong makaon diri kaydili jud ko ganahan satimpla sa mga pagkaonnga i-rasyon.´ asverbalized by the patient.O-
Vital signs takenas follows:BP: 130/70 mmHgTemp: 36.3 ºCHR: 87 bpmRR: 17 cpm
t: 78 kg from81.1 kgImbalance Nutrition: Lessthan bodyrequirementsrelated tounwillingness toeat.Adequate nutrition isnecessary to meet the body¶s demand. Nutritional status can beaffected by disease or injury state.In the case of my patient, her imbalancednutrition is due to her unwillingness to eat dueto unusual taste.Because of her medicalcondition, food preparations arechanged appropriate for her, but the change intaste is not easilymasked by the patient.(Gulanick/Myers; 2007; p. 134)After 3 days of nurse-patientinteraction, the patient will be able to demonstrate behaviour, lifestyle changesto regain appropriate weight.Specifically the patient will be able to:1)
Verbalizeunderstanding withcausative factors whenknown and necessaryintervention.The nurse will assistthe patient indemonstrating behaviour, lifestylechanges to regainappropriate weight.The nurse will:a)
Ascertainunderstanding of individual nutritionalneeds. b)
Discuss eating habitsincluding food preferences,intolerance andaversion.c)
Promote pleasantrelievingenvironmentincludingsocialization when possible.To determineinformational needs of the patient. ( Doenges,Morrhouse,Murr; 2009; p. 565)To appeal to client¶stasks. ( Doenges,Morrhouse, Murr; 2009; p. 565)To enhance intake.( Doenges,Morrhouse, Murr;2009; p. 565)GOAL METPatient was able todemonstrate behaviour, lifestylechanges to regainappropriate weight.GOALPARTIALLY METPatient was able to partiallydemonstrate behaviour, lifestylechanges to regainappropriate weight.GOAL NOT METPatient was notable to demonstrate behaviour, lifestylechanges to regainappropriate weight.