LEVEL 3 . NCM 104 .

2ND SEM SY 2010-2011

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Level 3

CASE PRESENTATION 2nd Semester SY 2010-11

I.

Statement of Objectives A. General Objectives This case analysis aims to increase the understanding and knowledge of student nurses on how to care for patients with Cholecystolithiasis effectively and efficiently. B. Specific Objectives

Specifically, this case analysis aims to: 1. 2. define Cholecystolithiasis and its effects to the body as a whole; illustrate the pathophysiology of Cholecystolithiasis and in relation to the signs and symptoms specifically observed in the client 3. 4. 5. 6. describe and identify the common signs and symptoms Cholecystolithiasis; discuss the medical and surgical interventions for the management Cholecystolithiasis; formulate appropriate nursing care plans suited for the client based on the assessment findings; identify care measures to be given to the patient and family to promote continuity of care and independence after discharge.

II.

Client s Profile

Name Age Birth date Sex Ethnic Background Civil Status Address Religion Occupation

: : : : : : : : :

Patient XX 17 years old December 31, 1993 Male Tagalog Single Dili,Bauang, La Union Roman Catholic Student

Admitting Diagnosis

:

Acute abdominal pain

2ND SEM SY 2010-2011 Page | Final/Principal Diagnosis Admitting Physician Date and Time Admitted : : : Cholecystolithiasis Dr. The client stated that he only had few cases wherein he was admitted to the hospital. Kidney problem or Cancer affected any of their family members. He also reported that he had no allergy to any medication as far as he knows. As of now. The patient also claimed that the pain was sometimes accompanied by vomiting. V. The pain was not radiating to the other parts of the body but was localized. After about an hour. He verbalized that. He took a tablet of paracetamol to relieve the symptoms but his condition did not improve. Past History of Illness The client had no history of any major abdominal problem and claimed that this was his first. . 2010 at 7:00pm III. Diabetes Mellitus.LEVEL 3 . not long and was relieved by simple means. NCM 104 . He also verbalized that his abdomen felt hard when he tried to massage it. Present History of Illness The client s condition started few hours prior to admission wherein he felt pain in his abdomen while he was celebrating the New Year with his family. none of his family members suffer from any illness as claimed by the client. The patient verbalized that he was able to tolerate the said symptoms for quite a long time. the pain became intolerable that he and his family decided to seek medical attention and hence admitted to Ilocos Training and Regional Medical Center. Further discussion revealed that he had experienced abdominal pain when he was in high school but the pain was tolerable. One of such was when he was confined due to convulsion when he was still an infant and another was when he had a dog bite when he was 12. no illness such as Hypertension. Cheryll Pagnas MD December 31. Chief Complaint Abdominal pain with vomiting IV. as far as he knows. VI. Family Health History The client claimed that he doesn t know of anyone from their family who suffers from any disease.

Lifestyle and Health Practices The client is unaware about the risks that lifestyle poses to his overall health. This was due to financial problems his family experiences. He is currently living with his parents and siblings and helps his parents in their livelihood. IX. . He states that he is contented on what he has. The family prefers to consult his grandmother who is a manghihilot and rely on home remedies.LEVEL 3 . He added that he and his friends enjoy playing billiards and computer games and sometimes just hang out in the plaza spotting girls. The house where they stay is made up of cement and metal. Fluid intake is 1-2 liters a day coming from carbonated beverages. their family can rarely afford to have access to medical services. The client stated that he sleeps for 7-9 hours every night. Role Confusion. No other vices were identified aside from those mentioned. Social and Environmental History As verbalized by the client. juice and water. He is a 17 year old single man who is living his life as it is. Because of this. He verbalized that he had no problem with himself in matters of self-image and stated that he doesn t have any problem with him being the firstborn in the family. which is composed of 2 females and a male.He is not much into sports thus views his daily chores as his form of exercise. They only go to the hospital in emergency situations and/or if they failed to treat the illness at home. NCM 104 . 2ND SEM SY 2010-2011 Page | VII. salty and sweet. He lives with his family and siblings near from the center of the city where central business take place. Water used daily is being supplied by NAWASA from which they also take their drinking water. Developmental History The client is the firstborn of the 3 siblings. He also said that he enjoys mingling with friends and loves going out with them. They value privacy as evidenced by separate bedrooms. he claimed that he does not smoke and that he drinks alcoholic beverages occasionally. VIII. He stated that his goals were simple such as finishing his studies. According to Erik Erikson s Developmental Theory. he is experiencing Identity vs. He is fond of eating flavorful food such as those that are spicy. He often eats food in eateries which serves home-cooked meals. The client claimed that his parents only finished vocational courses and that making charcoal is their family s source of income. He completes two to three meals in a day usually with snacks. The client verbalized that he last attended school when he was in 4th year high school but stopped during that year making him unable to graduate.

speech is well formulated. no lesions noted. evenly distributed. With a BP of 130/80 mmHg and PR of 88 bpm. Scapula is symmetric and non. Mouth Lips are moist without swelling. Nasal septum is intact. carotid pulses are bilaterally symmetrical. no lesions. trachea is located midline. Eyes The upper and lower eyelids meet completely when closed and pinkish conjunctiva. No murmurs were heard upon auscultation. no visible lesions and lice. He verbalized that he is 5 3 tall and weighs 48 kilograms. hearing is not impaired. Respiratory rate ranges from 22-24 bpm. 7. uvula located in the midline. 4. able to change direction of head without complaints of pain. Client appears weak. General Survey The client was received awake. Chest Appears symmetrical with ribs sloping downward. 6. and is free of swelling and foreign bodies.LEVEL 3 . No tenderness noted upon palpation. lumps or nodules. sitting on bed with an ongoing IVF s of D5LRS 1L x KVO infusing well on the left arm. mucous membranes are moist and light pink.Head Normocephalic. With a visual acuity score of 20/20 based on the Snellen scale. 2ND SEM SY 2010-2011 Page | X. Health Assessment A. moist and free of exudates.protruding. Cardiac Apical pulse with regular rate and rhythm. Nasal mucosa is dark pink. pupils equally round. Client doesn t use dentures on upper and lower teeth. No adventitious sounds heard upon auscultation. 2. Neck ROM intact. Client is an ectomorph. Tonsils are not inflamed. no enlargement noted. no complaints of pain upon palpation. 8. Head to Toe Assessment 1. Ears Equal in size bilaterally. Client is conversant. No tenderness upon palpation of lymph nodes. Nose and Sinuses Nasal structure is smooth and symmetric. oriented to the self and others around him. . He wears neat polo shirt and shorts and maintains proper hygiene. Hair is black. with no difficulty of distinguishing colors and no blurring of vision. Oral mucosa is dry. Jugular vein is not distended. B. 5. reactive to light and accommodation. Canals appear pink with minimal cerumen build-up. 3. No tenderness upon palpation of sinuses. NCM 104 . Client is able to sniff through each nostril while other is occluded. Lymph nodes are not enlarged. able to determine the time and date and is aware that he stays in a ward. Thyroid is located midline.

negative Protein. Shape of the abdomen is round and has a lighter color compared to the rest of the body. Musculoskeletal Upper and lower extremities are symmetric without lesions.5-8. 13: Integumentary Skin generally appears normal.0 Albumin. Breast (-) mastitis.3-4 HPF RBC. deformities.clear Normal Findings Color: pale yellow to amber Transparency-Clear to slightly hazy Specific Gravity. 10. Client is able to perform ADLs independently.1. 11.negative ProteinWBC.LEVEL 3 .0 Albumin. chemical and microscopic properties of urine. and are equal bilaterally in size. with normoactive bowel sounds heard in all the quadrants.2-3 HPF Epithelial cells. Good skin integrity. 2ND SEM SY 2010-2011 Page | 9. and physical.1-2 HPF RBC. . Skin is warm to touch. XI. 12. Client reported weakness in both extremities. 2010 Finding and Implication Result Color.Rare Mucus Threads. or swelling. Nails are smooth and trimmed.Rare Specific Gravity-1.negative Sugar. Diagnostics Diagnostic Procedure Urinalysis Description of the Procedure Analysis of volume.negative Sugar. Nipples are not inverted.yellow Transparency. Genitals Client does not complain of pain during urination.025 pH-4.2-3 HPF Epithelial cells-Rare Mucus Threads-Rare >Results reveals an elevated WBC count which may indicate an ongoing infection process. Abdomen Flat. NCM 104 . with direct tenderness upon palpation.030 pH-6.Trace(+/-) WBC. Good capillary nail bed refill of 1-2 seconds. Date of Procedure December 31. no organomegaly. With no abnormal discharges nor foul odor noted. nodules. soft. No palpable masses and no discharges noted. Areolas are dark pink in color.015-1. Significance/ Purpose of the Procedure Urinalysis gives us an index of how blood sugar is with the sugar spillage present in the urine and also the possibility of kidney failure with album loss in the urine as well as presence of UTI.

including diagnosis and guidance of treatment procedures. which are used for a variety of clinical applications. Sonogrophically unremarkable liver. . November 31. January 1.0-107.2 mmoL/L Chloride. >uses high frequency sound waves to produce twodimensional images of the body's soft tissues.2011 Result/Impression: Cholecystolithiasis. To measure and monitor the level of insulin secreted by the pancreas. kidneys.0 mmoL/L Sodium-135-141mmoL/L Sodium= 138. 2ND SEM SY 2010-2011 Page | Clinical Chemistry Ultrasound of the Abdomen Clinical chemistry uses chemical processes to measure levels of chemical components in the blood. >To assess/ see the underlying organs to evaluate degree of illness. The most common specimens used in clinical chemistry are blood and urine.LEVEL 3 .96. urinary bladder andprostate gland.2010 Result Potassium=3.0 mmoL/L >Results reveal decrease in potassium levels which may have result from excessive vomiting of the patient.5-5.3mmoL/L Chloride=99.44mmoL/L Normal Finding Potassium.3. spleen. NCM 104 .

LEVEL 3 . NCM 104 . 2ND SEM SY 2010-2011 Page | XII. Pathophysiology Predisposing factor Genes Diet Frequent intake of food rich in fat Precipitating factors Lifestyle Low level of activity Increased cholesterol secretion Accumulation of Calcium salts Accumulation of fatty acids Bile stasis Cholesterol supersaturation Biliary sludge formation Biliary cholesterol proportion becomes greater than biliary salt proportion Common bile/cystic duct blockage Formation of gallstones Solute crystallization Gallbladder distention Sharp pain in the right part of the abdomen Acute Pain Impaired venous and lymphatic drainage Bile stasis Gallbladder inflammation Bacteria proliferation Localized irritation Vomiting Infection Hyperthermia Risk for fluid volume deficit Anxiety Risk for imbalanced nutrition less than body requirements .

Significance >inhibits hypergastric secretion Generic name: metoclopramide hydrochloride Brand: Reglan Antiemetic 1 amp. jaundice. >preventsoccurance of nausea and vomiting Secondhand generation . >Urge pt. and blocks dopamine receptor at the chemoreceptor trigger zone.LEVEL 3 . >Tell pt. to avoid activities that require alertness for two hours after doses. Nursing Implication >Advise to report abdominal pain and blood in stool or emesis. headache. burning and itching at injection site. blurred vision. >Advise pt. malaise. Name Generic Name: Ranitidine hydrochloride Brand Name: Zantac Drugs Classification Dosage Antiulcer 50mg IV q 8 hrs . increases lower esophageal sphincter tone. to report persistent or serious adverse reactions promptly such as seizures. >Report if adverse reactions occur such as vertigo. >Remind to take once-daily prescription drug at bedtime for best results. Treatment/Management A. 2ND SEM SY 2010-2011 Page | XIII. Mechanism of Action >Competitively inhibits action of histamine on the H at receptor sites of parietal cells decreasing gastric acid secretion. IV PRN >Stimulates motility of upper G. NCM 104 . not to drink alcohol during therapy.I tract.

600 mg sodium chloride. >prevents infections caused by bacteria B. receiving drug IV to report discomfort at IV insertion site. Significance >For fluid and electrolyte replenishment and caloric supply. 30 mg of potassium hydrochloride. that inhibit cell wall synthesis that causes cell death. and is a source of water for hydration. This solution also contains lactate which produces a metabolic alkalinizing effect. to take drug as prescribed even he feels better. IV Fluids Name D5LRS Classification Hypertonic Component/s >It contains 5g dextrous hydrous. >Avise pt. NCM 104 . 310 mg sodium lactate. >Tell pt. It is capable of inducing diuresis depending on the clinical condition of the patient. Use and Effects > provides electrolytes and calories.LEVEL 3 . 2ND SEM SY 2010-2011 Page | Generic Name: cefuroxime sodium Brand Name: Zinacef Antibiotic 750 mg q 8hrs cephalosporin. .

Anxiety related to change in environment and unfamiliarity with procedures as manifested by worried gaze. . Risk for imbalanced nutrition less than body requirements related to inability to ingest adequate nutrition as manifested by weight loss. loss. Hyperthermia related to presence of infection as manifested by elevated body temperature. Basis of Prioritization Nursing Diagnosis and Rank 1. c. NCM 104 . Risk for fluid volume deficit related to excessive as manifested by dryness of mouth. 3. This is our 4th priority because it is still a potential problem and should be addressed before the actual problem. This is our last priority because if imbalanced nutrition is addressed there is lesser possibility of having FVD. According to maslow s hierarchy of needs food is one of the most important needs of human. This is our second priority because this needs to be addressed before the 3 as this is one of the presenting problem currently experienced by the client. Hyperthermia related to presence of infection as manifested by elevated body temperature. 5. Acute pain related to inflammation and distortion of tissues as manifested by verbal reports of pain and guarding behavior. List of Problems a. 4. Acute pain related to inflammation and distortion of tissues as manifested by verbal reports of pain and guarding behavior. b.LEVEL 3 . 2ND SEM SY 2010-2011 Page | XIV. Rationale This is the priority problem over the others because if pain was already addressed and given intervention. Anxiety related to change in environment and unfamiliarity with procedures as manifested by worried gaze. 2. Physiological problems should be addressed first before the psychological problem. Nursing Care Plans A. d. Risk for imbalanced nutrition less than body requirements related to inability to ingest adequate nutrition as manifested by weight This problem is our 3rd priority because it s a psychological problem. e. Pain will render patient unable to cooperate with interventions. 2. Prioritization of Problems 1. it is easier to address the others since pain is a great discomfort. Risk for Fluid Volume Deficit related to excessive as manifested by dryness of mouth.

Larry E.airmail. Derrickson Medical-Surgical Nursing: Clinical Management for Positive Outcomes.Willie Ong. Single Volume / Edition 7by Joyce Black.D. Procedures.Tortora. Ackley. Atlas and Registration Card.d.com/od/aftersurgery/qt http://web2. Gail B.html .org/wiki/cholecystolithiasis http://surgery. Juan Martin J. M.Michael L. 2ND SEM SY 2010-2011 Page | XV.org/blood_chemistry_tests.net/uthman/lab_test.Brunner and Suddarth Clinical Chemistry Principles. Redulla. R. List of References Medical Surgical Nursing 10th Edition.php http://en. NCM 104 .about. M.M. 11th Edition. Ladwig http://bloodindex. Edward P.LEVEL 3 .D.wikipedia. Correlations. Rhoda R.N Principles of Anatomy and Physiology. Bishop. Magsanoc. Anna Liza Ong. Schoeff Expanded Medical Blue Book 3rdEdition. Jane Hokanson Hawks Nursing Diagnosis Handbook 8th edition by Betty J. Fody.

STO: Goal met if the client will be able to: know the basic process of his condition be cooperative with nursing interventions A - > Review drug regimen.. possible side effects.Promotes gas formation. sucking on straw/hard candy. gravies. ice cream. gas producers (e. The interventions done to him is unfamiliar such as his prognosis.. Anxiety related to change in environment and unfamiliarity with procedures as manifested by worried gaze. - Tx Provide explanations of/reasons for test procedures and preparation needed. caffeine. however his unfamiliarity with the terms and procedures done to him makes him quite agitated and worried thusAnxiety. onions. . Goal and Objectives STO:  Within 1 hour the client will be able to: know the basic process of his condition be cooperative with nursing interventions Interventions Dx > Review disease process/prognosis. Discuss hospitalization and prospective treatment as indicated. Encourage questions.LEVEL 3 . whole milk. nuts. which can increase gastric distension/discomfort. necessitating long-term therapy. pain is one of the main contributors to increased level of anxiety Goal met if the client will be familiar and understand his condition and interventions done to him. expression of concern. O Frequently asking question about his condition. citrus)..g. pork).Information can decrease anxiety. Explanation of the Problem It is the client s first time to be confined in the hospital. Edx > Instruct patient to avoid food/fluids high in fats (e. .Gallstones often recur. or smoking. - name some procedures being done/given to him - name some procedures being done/given to him LTO  Within 2 hours of nursing intervention.g. > Encourage patient limit gum chewing. treatment and diet With worried gaze - . butter. thereby reducing sympathetic stimulation.g. LTO . spicy foods.Provides knowledge base from which patient can make informed choices. carbonated beverages). or gastric irritants (e. . beans. .Prevents/limits recurrence of gallbladder attacks and thus pain. 2ND SEM SY 2010-2011 Page | Rationale Evaluation Assesment S pwede bang maulitangsakitko . NCM 104 . the client will be familiar and understand his condition and interventions done to him.Some drugs can cause increased anxiety . Effective communication and support at this time can diminish anxiety and promote healing. fried foods. His condition is explained to him. cabbage.

NCM 104 . Because of vomiting excessive losses through normal routes occur thus Fluid Volume Deficit.Skin and mucous membranes are dry.LEVEL 3 . increased urine specific gravity.Decreases dryness of oral mucous membranes.Provides data for fluid source - LTO  Within 72 hours of nursing intervention the client will be able to manifest signs of normalized fluid volume such as moist mucous membranes. (+) body weakness (+) vomiting (+) dry mouth Explanation of the Problem The client s condition causes irritation to his GI tract. with decreased elasticity. > Provide skin and mouth care . Tx > Perform frequent oral hygiene LTO: Goal met if client will be able to manifest signs of normalized fluid volume such as moist mucous membranes. . . > Determine patient s beverage preferences. Assess skin/mucous membranes. . and set up a 24-hr schedule for fluid intake.Provides information about fluid status/circulating volume and replacement needs. peripheral pulses. decreased vomiting and good skin turgor. reduces risk of oral bleeding. noting output less than Intake. and capillary refill. . 2ND SEM SY 2010-2011 Page | Rationale Evaluation STO: Goal met if the client will be able to: Understand the importance of maintaining a normal fluid volume level Start fluid volume maintenance regimen Assesment S medyo nauuhaw ako O A Risk for Fluid Volume Deficit related to excessive as manifested by dryness of mouth. Goal and Objectives STO  Within 8 hours of nursing intervention the client will be able to: Understand the importance of maintaining a normal fluid volume level Start fluid volume maintenance regimen Interventions - Dx > Monitor and assess accurate record of I&O. because of vasoconstriction and reduced intracellular water. decreased vomiting and good skin turgor.

2ND SEM SY 2010-2011 Page | Edx  Encouraged to increase fluid intake .  Encouraged intake of food with high water content .LEVEL 3 .Relieves thirst and discomfort of dry mucous membranes and augments parenteral replacement. NCM 104 .Provides fluid replacement and maintenance .

body weakness Assessment S  Masakitang tagiliranko .  Rated pain 7/10. vomiting b. >Provide comfort measures such as back rubbing and changing in position. Interventions Dx: >Monitor vital signs To know any deviation from normal Pain is a subjective experience and cannot be felt by others. Administer analgesics as prescribed. the gallbladder becomes swollen causing pain. > Assess perception of pain. dry mouth d. O      grimacing Guarding behavior Self-focusing Restlessness noted Vital signs taken as follows: T.38 C RR. To provide nonpharmacological pain management. dry skin c. 2ND SEM SY 2010-2011 Page | Rationale Evaluation Is there still the presence of. a.88 bpm BP. LTO: Within 24 hours of effective ursing intervention the client will demonstrate use of relaxation skills and diversional activities and he will report pain is tolerable. Pain is a subjective experience and cannot be felt by others Observations may or may not be congruent.22 bpm PR. >Re-schedule nursing intervention and therapeutic activities without interfering client s rest periods. A> Acute pain related to inflammation and distortion of tissues as manifested by reports of pain. Pain is a subjective experience and cannot be felt by others To divert pain sensation To divert pain sensation To prevent fatigue . NCM 104 . The pain usually is felt in the right upper quadrant thus acute pain Goals and Objectives STO: Within 4 hours of nursing intervention the client will verbalize methods that provide relief from pain. listening to music. >Encourage diversional activities such as socialization with others. >Encourage adequate rest periods. To maintain acceptable level of pain. When gallstones block the flow of bile. Tx: >Observe non-verbal cues like facial expressions. >Encourage use of relaxation exercises such as focused breathing.LEVEL 3 .130/80 mm Hg Explanation of the Problem Formation of gallstones in the gallbladder may lead to the blockage of the bile ducts. Edx: >Encourage verbalization of feelings and concern about pain. poor skin turgor e. To provide rest. >Assess level of pain.

Explanation of the problem Due to the formation of gallstone. Because of these two factors. Goals and Objective STO: Within 2 hours of effective nursing intervention. >Evaporation is decreased by environmental factors of high humidity and high ambient temperature as well as body factors producing loss of ability to sweat.  . >Dysrhythmias and ECG changes are common due to electrolyte imbalance dehydration and direct effects of hyperthermia on blood and cardiac tissue. >Hyperventilation may initially be present.  Note presence or absence of sweating as body attempts to increase heat loss by evaporation.LEVEL 3 . conduction and diffusion.  >Promote heat loss by evaporation and conduction. the client will maintain core temperature within normal range. LTO: Goal met if the client will maintain core temperature within normal range. the client will demonstrate behaviors to monitor and promote normothermia. Provide tepid sponge bath.  Monitor respirations. but ventilator effect may eventually impaired by hyper metabolic state such as acidosis. >To determine the presence of hyperthermia. they will cause proliferation of bacteria causing infection. Dx:  Nursing interventions Rationale Evaluation Monitor core temperature. diarrhea and insensible losses. Distended bladder will now cause impairement in venous and lymphatic drainage and bile statis. >Promote heat loss by radiation and conduction. Because of the bacteria present our body will compensate causing an elevated body temperature. Tx:  Promote surface cooling by means of undressing or removing thick clothing. >To ensure safety. O> vital signs as follows: T> RR> PR> BP> >flushed skin >warm to touch A> Hyperthermia related to presence of infection as manifested by elevated body temperature. Provide a cool environment by opening windows and having fans. LTO: Within 8 hours of effective nursing intervention. STO: Goal met if the client will demonstrate behaviors to monitor and promote normothermia. 2ND SEM SY 2010-2011 Page | Assessment S> Mainit ang pakiramdam ko. NCM 104 . common bile will be blocked causing bladder distention and sharp pain in the right part of the abdomen.  Monitor all sources of fluid loss such as urine. vomiting. >Promote heat loss by convection.

2ND SEM SY 2010-2011 Page |  Promote safety by maintaining patent airway and padding side rails. Encourage adequate rest. >To reduce metabolic demand and oxygen consumption. >To offset increase oxygen demand and consumption.LEVEL 3 . Administer replacement fluids and electrolyte as prescribed.  Edx:   >To prevent fatigue.   Administer antipyretic as ordered. Provide oxygen supplements. Encourage adequate fluid intake. >To prevent dehydration. Administer medications such as antibiotic as ordered. . NCM 104 .   Maintain bedrest. >To maintain normal core temperature. >To treat underlying cause. >To support circulating volume and tissue perfusion.

: >pale in appearance >pain in the abdomen A>Risk for imbalanced nutrition less than body requirements related to inability to ingest adequate nutrition as manifested by weight loss. The bile statis now will cause a localized irritation in the abdomen causing now vomiting.    May have negative effect on appetite or eating To monitor effectiveness and effort It may lead to early satiety  Weigh weekly and as needed   . diuretics. Assessment Explanation of the problem The formation of gall stone in the bladder will cause the gall bladder to distend causing the impairment of venous and lymphatic drainage and bile statis. age.LEVEL 3 . STO: Within 8hours of effective nursing intervention. DX:  Assess understanding of individual nutritional needs  To determine what information to provide These factors may be affecting appetite .  .   LTO: Within 72hours of effective nursing interventions. Minimize/prevent unpleasant odors or sight. patterns and times of eating  To reveal changes that should be made in clients dietary intake To control underlying causative factors To enhance intake  Assist in developing individualized regimen   Promote pleasant relaxing environment and socialization when possible. NCM 104 . the client will verbalize understanding of causative factors and necessary interventions. body build.food intake.: Present wt. the client will demonstrate progressive weight gain toward goal. allergies. and absorption Provide comparative baseline  Assess drug interaction disease effects. TX:  Maintain diary of calorie intake. 2ND SEM SY 2010-2011 Page | Rationale Evaluation Goal met if the client will verbalize understanding of causative factors and necessary interventions and if he will demonstrate progressive weight gain toward goal. Goals and Objective Nursing Interventions S> wala akong ganang kumain O> weight loss Previous wt. Limit fiber/bulk if indicated.  Assess weight.

intolerances/aversions  To stimulate appetite To appeal clients likes and desires   . including food preferences. 2ND SEM SY 2010-2011 Page | EDX:  Encourage to choose foods that are appealing. NCM 104 . Discuss eating habits.LEVEL 3 .