ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION

Subjective: Independent: Independent:

No subjective cues. Imbalanced After 3days of 1. Take Px nutritional 1. It provides important Goal met After 3
nutrition: less nursing history with participation information about Px days of nursing
Objective: than body interventions, of significant others intake, needs, and interventions, the
* (+) Weakness requirements the patient will (since our Px is already deficiency patient will meet
* (+) Fatigue related to meet nutritional old). nutritional
*(+) Iron deficiency inadequate requirements as 2. Restrict Px sodium 2. This reduced requirements as
anemia diet, impaired evidenced by consumption (table salts, accumulation of fluid evidenced by
metabolism improved salty foods, all canned into patient peritoneal improved energy
and storage of energy level and frozen foods that are cavity that causes level with no body
vitamins with no body not specially prepared for ascites. weakness.
secondary to weakness. low sodium (should be
lover cirrhosis avoided.) 3. These are the most
as evidenced 3. Promote sufficient common micronutrients
by fatigue and nutritional intake such as deficiency in patient
body food rich in iron & with liver cirrhosis due
weakness. vitamin A,D,E,K. to impaired storage that
body can’t use as an
energy.
4. Elevate the head of the 4. It reduces discomfort
bed during meals. from abdominal
distention and decreases
sense of fullness
produced by pressure of
5. Promote appropriate abdominal contents and
diet for Px with liver ascites.
cirrhosis. 5. This diet helps to
avoid worsening of the
condition especially the
6. Give patient small sign and symptoms.
frequent meal.
6. Poor tolerance to
larger meals may be due
7. Provide oral hygiene to increased intra-
before meals. abdominal pressure and
ascites.
Dependent: 7. It increases patient
8. Encourage to take appetite and reduces
multivitamins as ordered unpleasant taste.
by the physician.
Dependent:
8. Patient should take at
least multivitamin and
mineral supplements that
Collaborative: meet 100% of dietary
9. Consult or refer to allowances as there is a
dietician for further reduction of food intake
evaluation and and deficiencies of
suggestions regarding various nutrients in liver
food partialities and cirrhosis.
nutritional assistance. Collaborative:
9. Dietician have a
broader knowledge of
the nutritional value of
foods and may be useful
in determining foods
appropriate for the
client’s condition.