DASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS S
Subjective: Imbalanced Short term: Determine in To meet nutrition Short term:
The patient nutrition: less than collaboration with requirements.
verbalized “ Wala body requirements After 4 hours of the dietitian the After 4 hours of
akong panlasa at related to inability nursing intervention number of calories nursing intervention
madali ako mahapo to ingest adequate the patient would be and type of nutrients the patient was able
kahit sa pagkain nutrients as able to needed. to
kaya nawawalan evidenced by
ako ng gana” fatigue, lethargy, Eat small frequent Provide needed To meet increased Eat small frequent
poor muscle tone, feedings that permit nourishment within nutritional feedings after a
Objective: lack of appetite eating when less limits of prescribed requirements. short nap
+ Fatigue fatigued and short diet.
+ Lethargy of breath
+ Dry skin Select nutritional To maintain Verbalize
+ Pale skin and Verbalize supplements. adequate caloric understanding in
conjucntiva understanding in intake. importance of
+ Poor muscle tone importance of balanced diet
Height: 5’6 balanced diet Administer enteral To meet nutritional Patient verbalized: “
Weight loss from feedings as ordered needs if patient Kakain ako ng
47 lbs to 41 lbs by the physician. cannot tolerate oral marami pag agahan
feedings. at magpapahanging
na ako lagi ng gulay
Monitor patient’s To prevent o prutas dahil
ability to tolerate shortness of breath mahilig naman ako
removal of oxygen and blood oxygen dun”
while eating. desaturation while
eating.
Goal Partially Met
Provide low- To reduce CO2
carbohydrate, high- production if
fat diet (e.g indicated for
Pulmocare feedings) patients with
Long term: respiratory acidosis. Long term:

After 1 week of After 1 week of

nursing nursing
interventions the interventions the
patient would patient would

Regain stabilized Regain stabilized

weight at preacute weight at preacute
illness weight of 47 illness weight of 45
lbs lbs

Goal Partially Met