ASSESSMENT DIAGNOSIS INTERVENTION MONITOR EVALUATION

SUBJECTIVE:
“awan ganas na nga Imbalance nutrition less  Assess the patient  Monitor the patient’s SHORT GOAL:
mangan” as verbalize by that body requirements nutritional status. weight on regular After 1 week of nutritional
his Lola. related to loss of appetite  Records the patient’s basis. intervention
as evidenced by lack of vital signs.  Monitor vital sign.  Patient nutritional
 Keep tract of the  Monitor the patient’s status has progress.
OBJECTIVE: interest in food, loss of
patient’s food intake. dietary intake and  Patient food diary
Name: Caiden James Valdez weight and weakness.
 Recommend appetite for any has no dietary
Male / 4 years old
nutrient-dense foods changes. changes.
BOD: May 9, 2019
to help stimulate  Encourage patient to  Patient may face a
appetite. keep a food diary to difficulty
Height :93cm
 Create supportive tract their daily food incorporating new
Weight 13KG intake.
environment that dietary habits.
Underweight  Evaluate the patient’s
Lack of interest in food promotes healthy
eating habits. nutrient intake.
Weakness  Monitor relevant
 Encourage regular LONG TERM GOAL:
Loss of weight laboratory values to
meals and snacks. After 3 weeks of nutritional
assess the patient intervention.
 Offer nutritional
nutritional status.  Patient dietary
supplements.
VITAL SIGNS:  Conduct a though changes and habits
 Develop a meal plan. clinical assessment to
RR:16 CPM are maintained over
 Collaborate with identify any signs or
PR:94 bpm dietitian. time.
symptoms of
TEMP:36’C  Address barriers to  Patient achieving and
nutritional
adequate nutrition. optimal nutrition and
deficiencies.
 Work closely with
meeting its body’s
registered dietitian to requirements.
review and interpret  Patient has healthy
the patient’s lifestyle changes to
nutritional data. support nutritional
 Schedule regular goals.
follow up  Consult with the
appointment to dietitian to interpret
assess the patient’s the patients
progress and make progress.
necessary
adjustment to
nutrition plan.