ASSESSMNET NURSING SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS RATIONALE INTERVENTIO

N
Subjective cues: Impaired Unfamiliar or Short term:  -Assess weight; -To establish After 1-2 hours of nursing
“Wala akong gana nutrition less unpalatable After 1-2 hours measure or baseline intervention the patient
kumain” as verbalized than body food of nursing calculate body parameters was able to:
by the patient. requirements as ↓
intervention the fat and muscle - Verbalized
r/t client will able to: mass via triceps understanding of
Objective cues: hypermetabolic Decreased -Verbalize skinfold and causative factors when
-Thin state associated strength and understanding of mid-arm muscle known and necessary
-weight-42kg with cancer AEB stamina causative factors circumference interventions.
-pale lack of interest in when known and or other - Participate in specific
food ↓ necessary anthropometric interventions to stimulate
interventions. measurements appetite/increase dietary
Decreased food
intake
- Participate in intake.
specific -Assess drug -That may be
↓ interventions to interaction, affecting
stimulate disease effects, appetite, food
Intake appetite/increas allergies, use of intake or
insufficient to e dietary intake. laxatives, absorption
meet metabolic diuretics. After 1week of nursing
needs
Long term: intervention the client
↓ After one week was able to
Imbalance of nursing -Determine -All factors that -Demonstrate behaviors,
nutrition less intervention the client’s ability to can affect lifestyle changes to
than body client will able to: chew, swallow, ingestion and/ regain or maintain
requirement. - Display and taste food. or digestion of appropriate weight
normalization of Evaluate teeth nutrition. Display normalization of
laboratory and gums for laboratory values and be
values and be poor oral health, free of signs of malnutrition
free of signs of and note
malnutrition denture fit as
indicated
-Display - Encourage - Metabolic
normalization of patient to eat tissue needs
laboratory high-calorie, are increased
values and be nutrient-rich as well as
free of signs of diet, with fluids (to
malnutrition adequate fluid eliminate
intake. waste
Encourage use products).
of supplements Supplements
and frequent or can play an
smaller meals important role
spaced in maintaining
throughout the adequate
day. caloric and
protein intake.

- Administer - Nausea and

antiemetic on a vomiting are
regular schedule frequently the
before or during most disabling
and after and
administration of psychologically
antineoplastic stressful side
agent as effects of
appropriate. chemotherapy.
-Refer to -Provides for
dietitian or specific dietary
nutritional team plan to meet
as indicated individual
needs and
reduce
problems
associated
with
protein, calorie
malnutrition
and
micronutrient
deficiencies.