Marciano, Karen Angelie

2NU03
CN: 16
Assessment Diagnosis Planning Intervention Evaluation
Subjective: Imbalanced Short Term Independent Intervention: Goal met, client was able to consume lunch
“my nutritional Goal:​Consume an 1. Weigh client as it is critical meal without any allergic reaction. Client was
cheekbones intake less than entire lunch meal with for objective assessment. also able to consult with a dietician and
have become the body’s proper nutritional value - Measuring and comparing all immunologist
so prominent requirement without any adverse future weigh-ins is crucial gather
and I don’t fit related to a reactions to the meal.” a baseline and compare any
into my severely Longe-Term Goal​: growth and deficiencies the
clothes restricted diet Patient will be able to client may have in the future.
anymore! It’s due to multiple consume an entire 2. Stay with patient to monitor
all because I food allergies. week’s worth of food full consumption of meal (s) and
have so many Evidenced by with proper caloric to monitor for any allergic
food allergies loss of weight. intake without adverse reactions.
now.” - as allergic reaction. - To see if client is able to
verbalised by tolerate a full meal. To be
the patients observe if client may present
Objective: with symptoms of an allergic
Height:​5’6 reaction to any ingredient in the
(1.6 meters) meal
Weight:​ 49 3. Keep strict documentation of
kilos urine input and output along
BP:​140/90 with caloric intake.
RR​: 17 - To be able to monitor how
HR​: 78 much the client is consuming
T​: 36.8 and how much the client is
Allergies:​poul excreting. To be able to compute
try, poultry how much caloric intake the
byproducts, client is able to retain.
seafood (fish Collaborative Intervention:
& shelled 1. Create a diet and meal plan
foods) with the supervision and
guidance of a dietician and
immunologist, catering to
patient’s multiple allergies.
- Client may able to thrive
outside of the hospital with full
control over their food
consumption that is within the
parameters of their food
allergies.