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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATIONSubjective:

Walang ganang kumain anganak ko as verbalized by themother


Objective:
Lack of interest in foodLoss of weightWeaknessVomiting after meals
Imbalance Nutrition less than
body requirements related toloss of appetite as evidenced bylack of interest in food, loss
of weight, weakness and vomiting
after meal
Inference:
Malnutrition
is the conditionthat results from taking anunbalanced diet in which certainnutrients are
lacking, in excess(too high an intake), or in thewrong proportions.
It is a broad term which refers toboth
under nutrition
(subnutrition) and
over nutrition
.Individuals are malnourished, orsuffer from under nutrition if their diet does not provide
themwith adequate calories andprotein for maintenance andgrowth, or they cannot
fullyutilize the food they eat due toillness.
Short Term Goal:
After 1 hour of nursing
intervention client will be able toConsume at least 50% of breakfast, lunch and dinner
traysat the end of the day

Long Term Goal:


After 1 week of Nursing
intervention client will be able toexhibit no sign and symptoms of malnutrition and will be
able togain 3 pounds at the end of theweek.
Independent:
Weigh client daily.
Weight lossor gain is important assessmentinformation.
Stay with client during meals
toassist as needed and to offersupport and encouragement.
Keep strict documentation of intake, output, and caloriecount.
This information isnecessary to make an accuratenutritional assessment andmaintain
client safety.
Suggest liquid drinks to themother

for supplementalnutrition.
Discourage beverages that arecaffeinated and carbonated.
These may decrease appetiteand lead to satiety.Collaborative:
Consult dietitian for furtherassessment andrecommendations regardingfood preferences
and nutritionalsupport.
Dietitians have aShort Term goal:
Goal met, after 1 hour of nursingintervention client consumed50% of her breakfast, 50%
lunchand 50% at dinner trays at theend of the day.
Long Term Goal:
Goal met, after 1 week of nursingintervention client exhibit nosigns and symptoms
of malnutrition and gain 3 poundsat the end of the week.

NURSING DIAGNOSIS: Altered nutrition: less than


body requirements
related to:

1.

2.

decreased oral intake associated with:


A.

anorexia resulting from decreased activity, depression and social isolation, the effect of
negative nitrogen balance, and early satiety that occurs with decreased
gastrointestinal motility

B.

difficulty feeding self as a result of impaired or limited physical mobility;

increased nutritional needs associated with an imbalance in the rate of catabolism and
anabolism (in the immobilized person, catabolic processes occur at a faster rate than anabolic
processes).

Desired Outcome

The client will maintain an adequate nutritional status as evidenced by:


1. weight within normal range for client
2. normal BUN and serum albumin, Hct, Hb, and lymphocyte levels
3. no further decline in strength and activity tolerance
4. healthy oral mucous membrane.

Nursing Actions and Selected Purposes/Rationales


1. Assess for and report signs and symptoms of malnutrition:
A. weight below client's usual weight or below normal for client's age, height,
and body frame
B. abnormal BUN and low serum albumin, Hct, Hb, and lymphocyte levels
C. weakness and fatigue
D. sore, inflamed oral mucous membrane
E. pale conjunctiva.
2. Monitor percentage of meals and snacks client consumes. Report a pattern of
inadequate intake.
3. Implement measures to maintain an adequate nutritional status:
A. perform actions to improve oral intake:
I.

II.

obtain a dietary consult if necessary to assist client in selecting


foods/fluids that meet nutritional needs, are appealing, and adhere to
personal and cultural preferences
encourage a rest period before meals to minimize fatigue

III.

maintain a clean environment and relaxed, pleasant atmosphere

IV.

provide oral hygiene before meals (removes unpleasant tastes, which


often improves the taste of foods/fluids)

V.

VI.

VII.

VIII.

IX.

serve frequent, small meals rather than large ones if client is weak,
fatigues easily, and/or has a poor appetite
implement measures to prevent gastrointestinal distention (e.g.
perform actions to prevent constipation, administer prescribed
gastrointestinal stimulants) in order to prevent feeling of fullness and
early satiety
encourage significant others to bring in client's favorite foods unless
contraindicated and eat with him/her to make eating more of a
familiar social experience
encourage significant others to be present to assist client with meals if
needed
allow adequate time for meals; reheat foods/fluids if necessary

X.

XI.

XII.

limit fluid intake with meals (unless the fluid has high nutritional
value) to reduce early satiety and subsequent decreased food intake
enable client to feed self if possible; if client needs to be fed, offer
foods/fluids in the order he/she prefers
increase activity as allowed (activity usually promotes a sense of wellbeing, which can improve appetite)

B. ensure that meals are well balanced and high in essential nutrients; offer
high-protein, high-calorie dietary supplements if indicated
C. administer vitamins and minerals if ordered.
4. Perform a calorie count if ordered. Report information to dietitian and physician.
5. Consult physician about an alternative method of providing nutrition (e.g. parenteral
nutrition, tube feedings) if client does not consume enough food or fluids to meet
nutritional needs.