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RLE 002

Cebu Normal University
College of Nursing Cebu City
Mission-Vision: “Care Using Knowledge and Compassion” Theory-based (Betty Neuman)

Assessment 3 points Goals Diagnosis 3 points Theoretical Basis 2 points 2 points Evaluation Interventions 1 point 4 points 15 points Bibliography

Name of Student:_Judaperl D. Cabanag _________________ Client’s Initials:__A.C______________________________________ Age: 37 y/o Gender: Male Civil Status:Single Religion:R. Catholic Allergies: _no known allergies to food and drugs_____________ Diet:_NPO________________________________________________ Date of Admission:_January 7, 2014; 4:15pm ____________ Diagnosis/Impression:Acute Appendicitis, Uncomplicated _

Clinical Instructor: _Mr. Julius C. Daño, RN_________ Stressor Classification: (Please check) ____ Physiological (body structure and functions) ______ Psychological (mental processes and emotion) ______ Socio-cultural (relationships, expectations) ______ Spiritual (influence of spiritual beliefs) ______ Developmental (developmental processes over the lifespan)

Assessment Subjective: “Magsige man gud ug sakit ako’ng tiyan mao ng di ko ganahan mukaon 9 days na,” as verbalized by patient Objective:  received conscious and coherent  restlessness noted  reported weight loss of 2 kg in one week  reported to have decrease in appetite Diagnosis Imbalanced Nutrition: Less than Body Requirements related to decreased appetite secondary to constant abdominal pain

Mutual Planning
(Goal attainable within the shift)

(with Rationale & Source)

Actual Evaluation

After eight hours of nursing interventions, patient will be able to:  verbalize understanding of appropriate food intake and diet restrictions;  take in an increase quantity of foods with necessary nutrients with gradual diet progression

I: Explain to the patient and family the rational of proper diet and why restriction is being implemented. R: Understanding promotes cooperation S: Gulanick/Myers, 2007 I: Teach pain management such as focused beathing, positioning and diversion. R: Decreases perception of pain which contributes to decreased appetite. S: Gulanick/Myers, 2007 I: Provide hard candy for patient. R: Helps in salivation thus, increases will to eat S: Gulanick/Myers, 2007

Theoretical basis:  on NPO status for 2 days  with sthenic body built  reported to have abdominal pain which ranges from mild to moderate pain  with normoactive bowel sounds  dryness of oral mucosa noted  pain score: 2 out of 10 Adequate nutrition is necessary to meet the body’s demands especially when having diseases since this can help in providing the body with the essential nutrients and minerals to aid in recovery. Nutrition on can be affected by disease states which could involve discomfort in taking in food as well as diet restrictions. During times of illness, adequate nutrition plays an important role in maintenance of the wellbeing of the patient; however, appetite may decrease illness states. - Smeltzer and Bare, 2010

I: Encourage to eat small but frequent feedings. R: Promote adequate intake of nutrients with decreased energy levels to prevent early satiety. S: Gulanick/Myers, 2007 I: Provide assistance and encouragement to eat more as needed during mealtime. R: Patient may need help with eating. S: Kemper, 2005

I: Consult dietitian for further assessment and recommendations regarding preferences and nutritional support. R: Dietitians have a greater understanding of the nutritional value of foods. S: Gulanick/Myers 2007 I: Administer vitamin and mineral supplements, as ordered. R: Nutrient supplements may be indicated to reduce deficiencies. S: Kemper, 2005

I: Weigh patient at regular intervals. R: Monitor changes in body weight. S: Smeltzer and Bare, 2010 I: Encourage significant other to provide patient’s favorite food but with more on vegetables and fiber. R: This encourages patient to eat while taking in appropriate nutrients. S: Gulanick/Myers, 2007

_______Gulanick, M & Myers, J. (2007). Nursing Care Plans. 6th ed. Elsevier (Singapore). Pte. Ltd.____________________________________________ ________Kemper, D. (2005). Healthwise Handbook. Healthwise, Incorporated, Boise Idaho.__________________________________________________ ________ Smeltzer, et. Al (2010). Brunner & Suddharth’s Textbook of Medical-Surgical Nursing. 12th ed. Wolters Kluwer Health Lippincott Williams & Wilkins._