Time Chart

8:00 -4:00 pm F> Imbalanced Nutrition: Less than body requirement

as evidenced by weight loss and muscle weakness
D> Received lying in bed with intact IVF of PNSS x
KVO; with reported persistent difficulty in gaining
weight, severe nausea, and anorexia; with VS as
follows: BP-90/60 mm/hg, weight- 32.7 kg, BMI- 14.5
kg/m2; weight loss; with pale and dry skin; with muscle
weakness
A> Assessed general appearance and monitor VS;
Ascertained understanding of individual nutritional
needs like food in high protein and low potassium;
Assessed weight, age, body build, strength and rest
level; Identified at risk for malnutrition due to chronic
illness like renal failure; Provided diet modification as
indicated (high protein and low potassium diet);
Maintained bed rest; Positioned the bed into semi-
fowler’s; Changed position every 2 hours; Minimized
fluid intake as ordered; Encouraged early ambulation;
Encouraged to do passive range of motion exercise;
Promoted relaxing environment
R> After 8 hours of nursing intervention, the patient
was able to verbalize understanding of significance of
nutrition to healing process and general health as
manifested by demonstrating behaviors, lifestyle
changes to regain and maintain appropriate weight

DATA GOALS/ ACTION/NURSING RATIONALE RESPONSE AND

Expected INTERVENTIONS EVALUATION
outcomes
Subjective STG: within Dxt: After __8_ hr/s of
findings: 8__ hour/s of  Assess general  To establish NI, the patient
- reported NI the patient appearance and baseline data was able to
persistent will be able to monitor VS verbalize
difficulty in verbalize  Ascertain  To determine understanding of
gaining understanding understanding of what information significance of
weight, of significance individual to provide the nutrition to
severe of nutrition to nutritional needs patient healing process
nausea, and healing process like food in low and general health
anorexia and general protein and low as manifested by
health as potassium demonstrating
Objective manifested by  Assess weight,  To provide behaviors, lifestyle
findings: demonstrating age, body build, comparative changes to regain
-with VS as behaviors, strength and rest baseline and to and maintain
follows: BP- lifestyle level identify appropriate weight
90/60 changes to deviations from
mm/hg, regain and normal STG:
weight- 32.7 maintain assessment fully/partially/un
kg, BMI- appropriate  Identify patient  To assess for MET
14.5 kg/m2 weight at risk for contributing
-weight loss malnutrition due factors After __8_ hr/s of
-pale and LTG: within to chronic illness NI, the patient
dry skin _3_ days of NI like renal failure was able to
-muscle the patient will Txc: display nutritional
weakness be able to  Provide diet  To establish ingestion sufficient
display modification as correct to meet metabolic
nutritional indicated nutritional plans needs as
Focus/ ingestion (decrease protein manifested by
Nursing Dx: sufficient to and low weight gain within
(PE/S) meet metabolic potassium diet) 10 % of ideal body
needs as  Maintain bed rest  To decrease weight and
Imbalanced manifested by metabolic exhibits improved
Nutrition: weight gain demand energy level
Less than within 10 % of  Position the bed  Aids in
body ideal body into semi-fowler’s swallowing and
requirement weight and reduces risk of LTG:
as evidenced exhibits aspiration fully/partially/un
by weight improved  Change position  Changing MET
loss and energy level of the patient positions prevent
muscle every 2 hours ulcerations
weakness
 Minimize fluid  To prevent water
intake as ordered retention
Edx:
 Encourage early  To prevent
ambulation muscle atrophy
 Encourage to do  To have proper
passive range of circulation of
motion exercise blood
 Promote relaxing  To enhance
environment intake