Assessment Nursing Goals and Expected Nursing intervention Rationale of Evaluation

Diagnosis Outcomes Intervention

Subjective: “hindi Imbalance nutrition(less Demonstrate behaviors, lifestyle Identify clients at risk for To know what are the possible Goal partially met,
siya makakain ng than body requirements) changes to regain and maintain malnutrition factors that can affect the client demonstrate change
mayos dahil R/t inability to ingest appropriate nutrition and weight. nutritional balance in eating habit but it
masakit food due to presence of (e.g. Restricted intake, has no increase in
lalamunan niya” mass in the splenius inability to chew, swallow or weight.
“tyaka ang guto muscle taste)
nyang lagging
kainin ay Discuss eating habits, including To appeal to clients likes or
milktea” food preference or intolerances desires
Sa verbalized by
the SO Use flavor agents (e.g. lemon and To enhance food satisfaction
herbs and stimulate appetite

Objective: Assess weight, age, body, Provides comparative baseline

(+) body strength activity / rest level. on patient
weakness
(+) dry lips Giving soft diet To lessen the pain in throat
Decrease wt by 1
kg consult dietician/ nutritional To implement interdisciplinary
team as indicated team management and to
provide the proper meal for the
patient

promote pleasant and relaxing To enhance food intake

environment
 Assessment Nursing Diagnosis Goals and Expected Nursing intervention Rationale of Evaluation
Outcomes Intervention
Subjective: Disturbed sleeping pattern To promote improvement in Identify factors contributing To know what are the priorities to Goal met, the client
“madali siyang r/t noise and sleep privacy sleep and rest pattern during to disturbance of sleep eliminate or solve demonstrate active
magising at or control the whole shift movements and has rest
nagugulat siya kahit Review psychologic To know how to deal with patient and sleep well.
konting kalabog lang assessment through its own physiologic life
lalo na at nasa ward style
kami” as verbalized
by the S.O.
Observe and obtain feedback To determine usual sleep pattern
Objective: from client or SO regarding of and provide comparative baseline
(+) body weakness usual sleeping pattern
(+) pale in eye
mucus membrane Observe physical sign of
(+) eye bags fatigue

Encourage the others to To rest and sleep properly

observe silent to provide
peace environment for the
patient