Assessment Nursing Diagnosis Planning Intervention Evaluation

Objective: Imbalanced Nutrition: After 5 days of nursing After 5 days of nursing

- Weight (91lbs Less than body intervention the 1. Conduct a intervention the
or requirements related to patient will maintain an comprehensive patient has maintained
41.2 kg) malnutrition. adequate nutritional nutritional an adequate nutritional
- (Stage 2) status as evidence by assessment status as evidence by:
pressure injuries were
a.) Increase body 2. Determine client’s a.) Increased body
present on both
weight nutritional history weight from 42.1kg to
buttocks
including a 50 kg
preferred food
Subjective: The b.) Verbalize the intake b.) The patient was able
husband verbalized importance of to verbalized the
that his wife is nutritious food 3. Monitor and record importance of
“picky” to eat and the patient’s food nutritious food
drink. and fluid intake
Goal met.
4. Encourage, small
frequent meals and
snacks to improve
caloric intake

5. Avoid foods that

stimulate gas
production

6. Encourage patient
to choose nutritious
food such as
vegetables, fruits
and low fat-foods

7. Educate the
husband on the
importance of
nutrition and
provide guidance on
meal preparation.