Assessment Planning Evaluation

Subjective data: Goal Interventions/ Implementation Rationales Patient respond effectively to

Coughing too much but Evaluation
unable to Short goal: 1. Assess respiration: quality, 1. To establish a Planning
the interventions as shown
bring out the secretion and difficulty
Patient respondTheeffectively
child will Rationalespattern, depth and auscultate
Interventions/ Implementation
comprehensive Goal by: Nursing Diagn
in breathing as reported to
bythe
theinterventions
demonstrate
as shown 1. Forthe lungs. date.
baseline 1. Assess theassessment
child’s sleepand to Short-Patient's
goal: RR within normal
Disturbed sleep p
patient. by: effective 2. Assess
2. Excessive noiseand observe the pattern. know any changes in range.
The child will frequently cough
-patient report improvement
coughing and coughing
causes sleep pattern and the 2. Provide quit,
childdark
condition.
and report-Patient's airway
byremain
presence of d
Objective data: in quality of sleep
increased
pattern.air character of sputum
deprivation. 2. To environment.
comfortable patent without
plan and select improvement in any
eyessecretions.
and restless
-Wheezing sound. -patient demonstrate
exchange within 3. 3.to effectively
Position the patient in 3. Provide comfortappropriate
measures quality -Patient maintain normal
of sleep
-Retained secretion and measures
mucus. to improveone day.
sleep. semi-fowler
promote sleep. position with such as (back interventions.
massage). breathing
pattern within 3pattern and breath
-ineffective coughing. -patient feel comfortable as 4. To head flexed,
increase shoulder 4. Explore
quality 3. other
To facilitate clearinghr. easily without any
sleep aids secretion
Subjective data:
-RR: 46 bpm evidence by reduce
Longdark
goal: relaxed and knees flexed. (warm bath
of sleep. of or
themilk).
secretion, and -Patient able toThe
demonstrate
child unable
-Spo2: 97% circle under hisThe
eyes.
child will 5. 4.Caffeine
Encourage the child to take
can also 5. Discouragepromote
caffeine better
or lungs deep breathing weeks
and coughing
as mother
-HR: 147 b/m. maintain patent more fluids.
interfere with sleep. large mealexpansion and
intake before exercises.
-T: 39.5c airway by the 6. 5.Carbohydrate
Encourage and causeteach the improve
the child goes Long-Patient
air exchange.
to sleep. goal: feels comfortable
time of childofto do deep breathing6. Take carbohydrates
release 4. Adequate hydration
such without
The child willany secretion
Objectivein the
data:
discharge. and coughing exercise.
neurotransmitter can
as crackers facilitate
before airway.
loosendemonstrate
bedtime. -Looks tired.
Nursing Diagnosis: 6.serotonin
Chest physiotherapy
which 7. Administersecretion
cough by liquefy measures
it. to -Restlessness.
Ineffective airway clearance 7.helps
Suction
induce theand
secretion when medication
5. Toifremove
needed secretion
as improve sleep by -Presence of dark
related to retained secretion and needed.sleep.
maintain from airway.
doctor’s order. the time of eyes.
excessive mucus as manifested by 7. 8.To Administer
minimize humidified 8. Reassess 6. the
clear the airway
child’s sleep anddischarge. -T: 39.3c
ineffective cough, wheezing sound oxygenand
coughing as prescribed. . pattern. make breathing -HR: 147 b/m.
and difficulty in breathing. 9.enhance
Administer the antibiotic &
sleeping. effective. -RR:46 bpm.
8. To bronchodilators
evaluate the as 7. To remove the
physician.
nursing intervention. secretion and maintain
patent airway.
8. To loosen secretion
and improve
ventilation.
9. To reduce
inflammation &
enhance the breathing
 Evaluation Rationale Implemente Goals/Outcomes Nursing Diagnosis
Interventions #

1- patient’s RR 1- provide a basis 1- Monitor rate, Short term goal:

within normal for evaluating rhythm, depth and The client will achieve
range. adequate effort of respiration. a comfortable
ventilation. breathing pattern
2- Patient 2- Monitor the color within 3 hours.
breathes 2- Cyanosis of skin and mucous Ineffective breathing
normally. involving the membrane. pattern related
mucous may to secondary to TTN, as
3- Patient’s indicate further evidenced by rapid 1.
ABG level reduction of O2 3- Auscultate for Long term goal: breathing of 65b/min,
remains level. breathing sounds. The client will tachypnea, Spo2 of 90%
normal. maintain a normal and nasal flaring.
3- To detect for breathing pattern by
adventitious 4- Assess ABG discharge.
sounds. level.

4- To monitor 5-Encourage the

oxygenation and family for the
ventilation status. importance of
keeping CPAP
5- To help relieve mask.
respiratory
distress.

.
Evaluation Rationale Implemente Goals/Outcomes Nursing
Interventions Diagnosis #
 . Ineffective
Goals met: 1-to obtain baseline 1- Monitor Vital signs; Patient will maintain/ airway
data. respiration, pulse, blood clearance
improve
- Patient pressure, temperature. RT
maintains normal airway clearance within
breathing. 2- Keep the patient 30 mint respiratory
2- Systemic hydration adequately hydrated. distress
keeps secretion moist AEB absence of signs
-Patient’s RR AEB
and easier to of respiratory distress:
within normal expectorate. 2.
range. Reduce secretion Cough
3- To loosen secretion. 3-Use humidifying. Secretion
-Patient’s airway Normal breathing
remains patent. 4- To improve lung Difficulty in
expansion. Patent airway.
breathing
4- Elevate head of the bed
and change position of the Nose
patient every 2 hours. blocking
5- To open the airway.
5- Administer
bronchodilators as
prescribed.

Evaluation Planning Nursing

 Diagnosis
The goal was Rationales Interventions Goal
met: Short goal:
1-Assess respiratory Ineffective
-The patient
rate. The patient will breathing
demonstrates
1-To know any changes in 2-Apply oxygen mask demonstrate effective pattern related
effective
client condition for patient. coughing and increased to
coughing and
2-To provide patient with 3-Make child to set in exchange within 1 day. Tracheobronch
increased
more Oxygen. semi-fowler position al obstruction
exchange.
3-To allows maximum 4-Auscultate breath shortness of
- The patient
chest expansion sounds note breath
maintains patent
4-Some degree of adventitious breath Long goal: manifested by
airway by the
bronchospasm is present sound cough for 7
time of discharge.
with obstructions in the 5-If cough is The patient will maintain days,
airway and this produce ineffective, use patent airway by the time tachypnea,
-SPO2=97%.
wheezing sound. nasotracheal of discharge. respiratory
- RR=48br/min
5-To remove sputum & suctioning as needed. distress and th
-HR=118/min
mucous plugs. 6-Use humidifying. Respiratory
6-To loosen secretion. Rate
7-Administer &
7-To open the airway. bronchodilators (RR=50 br/mi
nebulization as spo2 85%
physician's prescribed.
Assessment Nursing Goal Nursing Rationale Outcome
diagnosis orders/intervention criteria

:Subjective data Deficient Short term Assess level To obtain a Patient

knowledge :goal of .baseline date maintain
Patient asked frequently related to The .knowledge enough
.about her/his condition lack of patient's To increase knowledge
exposure to knowledge the about her/his
information about Encourage knowledge .condition
: OBJECTIVE data and her/his patient to about her/his
resources condition .ask .condition Patient will
Facial for follow will seek
Expressions looks (worry) up care as increase Use To ensure the assistance
manifested within 1 terminologies understanding .appropriately
:Vital signs by frequent .hour easy to .of the patient
questioning understand Patient will
T=36.8C about by the To reduce the describe
P=76 b/m her/his .patient anxiety of the her/his
RR=20 b/m .condition .patient .condition
=BP Long term Answer all
132/93mmHg :goal the questions To ensure the Patient
The .of patient understanding expresses an
patient .of the patient understanding
will Speak slowly of the
maintain and To evaluate condition and
adequate frequently the treatment
knowledge repeating the effectiveness .program
about .information of nursing
her/his .intervention Patient
condition Reassess describes
by level of her/his health
.discharge .knowledge status
.appropriately
Evaluation
After 8 hours of Rationales
nursing intervention,
the patient was able to:
-Maintain Pao2 and 1-Positioning the patient in
Paco2 levels within the proper alignment helps
normal range or within maximize ventilation
his baseline status. potential and improve gas
exchange by allowing
-Demonstrate that expansion of the lungs.
breathing is easier.
2-Oxygen provides
symptomatic relief of
hypoxemia or hypoxia.
-Demonstrate that
fatigue is reduced.
3-Oxygen can dry out the
mucous membranes.
-Use correct breathing
techniques. 4-To prevent growth of
microorganisms.
5-These test results
indicate the lungs ability to
oxygenate the blood.
Planning Nursing Diagnos
Interventions/ Implem Goal Impaired gas exc
entation related to obstruc
1- Assist the patient After 8 hours of nursing of airways by
to keep his head, neck, intervention the patient secretions and
and chest in will: bronchospasm.
alignment. Manifested by
coughing, wheez
2-Administer oxygen noted secretion
as ordered. -Monitor Pao2 and Paco2
levels to assess if they're SUBJECTIVE:
3-Provide mouth care within. normal range of the
every 8 hours and as patient's baseline values. Fatigue, cough fo
needed, and assess days, wheezing
nasal and oral mucous -Monitor level of
consciousness, heart rate, OBJECTIVE: br
membranes for
and respiratory rate. sound Decreased
cracking.
Tachypnea, SPO
85%, RR 50/min
4-Clean the cannula or
160/min.
mask by rinsing with -Monitor energy level.
clear, warm water
every 4 to 8 hours or
as needed.
-Monitor alveolar
5-Monitor the results clearance.
of ABG analysis and
pulse oximetry, and
document any trends.
 Prioritized Goals/ Nursing Intervention
Assessment Rationa
Nursing Outcomes Criteria Planned
Done
Diagnosis (PES)
Subjective Acute pain 1. Assess for pain. Note 1-Sickling o
Patient verbalized that related to location, duration, and potentia
he had headache, occlusion of intensity (scale of 0-10) cellular hy
upper &back pain small blood Short Term 2. Provide support and DON and may le
(8/10) in pain scale vessel as The patient will able carefully position E infarctio
and vomiting. evidence by the to relive pain from (8 affected extremities tissues w
patient to 4) in pain scale 3. Massage gently affected resultant
complains of whiten two hours areas. Pain usu
local pain 4. Plan activities during DON occurs in
severity 8/10 peak analgesic effect. E back, ribs
and inability to 5. Maintain adequate fluid limbs and
move affected Long Term: intake. DON last for d
joint. 6. Apply warm, moist E 2- To reduc
The patient will able compresses to affected edema,
to: joints and other painful discomfort,
1-verbalize relive or areas. Avoid use of ice DON risk of injur
control of pain. or cold compresses. E especially if
2- Demonstrate osteomyelit
Objective : relaxed body posture. DON present.
3- Rest and sleep E 3- To Help r
WBC= 10.57K/uL rise appropriately and muscle tens
HGB = 9.93g/Dl low have freedom of DON 4- To maxim
Bp:122/77mmHg movement. E movement o
4-Take the pain killer joints, enha
medication as mobility.
prescribed by the 5- Dehydrat
 increases
sickling/vas
occlusion an
correspond
pain.
6- Warmth
doctor to reduce the vasodilation
pain increases
circulation t
hypoxic are
Cold causes
vasoconstri
and compou
the crisis.
 Rationale Nursing Goals / Outcome Nursing Diagnoses (Actual)
(1 mark) orders/interventions Criteria (2 marks)
(5 Marks) (1 mark)

1-hypotension, rapid, 1-Carefully monitor vital To improve tissue

weak, and thread pulses, signs (bp=122/77mmHg, perfusion Altered tissue perfusion related to vaso-
and increased or shallow pulse=65/min, RR= 19/min) occlusive nature of sickling, affinity of
respirations are signs and Outcomes: hemoglobin for oxygen as manifested by
symptoms of diminished Tingling in extremities, intermittent
tissue perfusion Patient will: claudication and bone pain as manifested
2-Assess skin of pallor, Subjective data:
2-Changes reflect cyanosis, coolness, 1-Have normal vital signs He said: ''he is unable to move actively du
diminished circulation diaphoresis, and delayed within 2 hours to he feels of fatigue''
and/or hypoxia capillary refill. (Patient skin Objective data:
potentiating capillary is pale|) 2-Maintain adequate fluid Patient looks pallor.
occlusion intake within 1/2 hour Low of haemoglobin (9.93 g/dL).
3-Maintain adequate fluid
intake (8 glasses per day) 3-skin color will be
normal within 2 hours
3-Dehydration causes
increase in sickling and
occlusion of capillaries 4-Assess the lower
other than hypervolemia extremities for skin texture,
ulcerations, and/or edema (no
4-Sickling of blood can ulceration or edema)
cause reduced peripheral
circulation and often leads 5-Maintain room temperature
to dermal changes and and body warmth without
 overheating
delayed healing.
6- instruct patient to avoid
5-This prevents physical exertion, emotional
vasoconstriction therefore stress, low oxygen
aids in maintaining environments (High places)
circulation and perfusion

6-Decreased activity and 7-Monitor and note changes

osure reduce body need in level of consciousness,
for oxygen reports of headache,
dizziness, development of
sensory and motor deficits
(hemiparesis or paralysis)
7-Changes observed may
reflect diminished
perfusion to the central
nervous system (CNS)
due to ischemia or
infarction. Stagnant cells
must be mobilized
immediately to prevent
further
ischemia/infarction and
seizure activity

The short goal was meet: 1-Assesing the pain help in 1.Assess level of pain. Short Term Acute pain related Subjective data:

After 8 hours of nursing
intervention the client was
able to report manageable
level of pain from (6 to 3) in
pain scale.
Long term was met: by time
discharge, the patient able to:
-Verbalized relieved and
controlled of pain
-Demonstrated relaxed body
posture by performed
relaxation technique.
-The patient had rested and
sleep appropriately and had
freedom of movement
-The Patient was taken
medication as prescribed
determining the Note location, duration, After 8hours of nursing to uterine cramping patient said ‘’I have
interventions needed to and intensity (scale of 0- intervention, the patient secondary to the pain in lower back
10)
relieve such pain. will able to report expulsion of some and pelvic”. The
manageable level of pain products of pain level was 6/10
2- To promote relaxation 2.Provide a quiet from (6 to 3) in pain scale.
conception as in pain scale.
and enhance patient coping environment. evidence by the
abilities. Objective data:
patient complains of
3. provide other non-
3- provide other non- Long Term: pain severity 6/10 Facial expiration
pharmacologic
pharmacologic interventions: massage in pain scale in (sad& tired),
After 2 days of nursing lower back and Vital signs: T:36.8
interventions: massage therapeutic touch.
intervention, the patient pelvic.
therapeutic touch HR: 71 bpm
will able to:
4.. Instruct patient to do
4- Breathing exercise is a BP: 112/50mmHg
relaxation techniques 1-verbalize relive or
relaxation technique that (Deep breathing) control of pain. RR:20/min
reduces pain by relaxing
tense muscles that 5 Document patient’s 2- Demonstrate relaxed
contribute to pain. response to pain body posture.
5- It helps the entire management. 3- Rest and sleep
healthcare team evaluate appropriately and have
their pain management 6. Administer analgesic as
freedom of movement.
prescribed
strategy.
4-Take the pain killer
6- To reduce the pain. medication as prescribed
by the doctor to reduce the
pain
 Evaluation Rationale Intervention Goals Diagnosis Assessment
s
Short term 1-These 1-Assess for
was met: moods may be feelings of Short term: Powerlessness Subjective
After 6 hours an element of apathy, related to
data:
of IN the powerlessness. hopelessness, Within 8 hour early loss of
patient able or providing pregnancy patient
and
to: 2-Patients are depression. proper nursing secondary to verbalized
•Express usually able to interventions, ectopic she became
sense of recognize pt. will be pregnancy as sad and
2-Determine
control over those able to: evidenced by
the patient’s depressed
the present perspectives •Express patient feel
power needs after lose
situation and of self- sense of depressed and
or need for sad after lost her fetus.
future governance control. control over
outcome. that they miss the present her fetus. Patient said
•Acknowledge most and that 3-Encourage situation and "I can’t do
reality that are relevant to an increased future anything, I
some areas are them. responsibility outcome; loss my
beyond for self. power".
individuals 3-The •Acknowledge
control perception of 4-Encourage reality that
powerlessness verbalization some areas are
Long term may negate of feelings, beyond
Objective
was met: the patient’s thoughts, and individuals
After 2 days attention to concerns control data:
of IN the areas in which about making Patient
patient able to self-care is decisions. facial
make choices attainable
expressions
related to and Long Term were sad
be involved in 5- Encourage Goal: Within and tired.
care. 4-This the pt to rest b 2 days of
approach providing
creates a 6-Note proper nursing
supportive nonverbal interventions,
environment behavioral pt. will be
and sends a responses able to make
message of choices
caring. 7- Encourage related to and
5- To promote use of anxiety be involved in
adequate rest. and stress- care.
6-Gestures reduction
and nonverbal techniques
cues are such as
significant in thinking of
looking deeper happy
into what a thoughts and
person feels. positive self-
recitation life
7- To promote
wellness

Evaluation Rationale Interventions Goals Diagnosis Assessment

GOAL WAS 1) To detect 1) Assess the
Risk for Objective
MET: early signs of signs and
Goal: infection data:
infection and symptom of
1- Patient was (including
free from any provide good infection (pain, The patient Bleeding
pelvic (dilated
s/s of infection treatment swelling, will remain
inflammatory cervix)
redness…) free of
2- Had normal 2) Due to disease)
infection, as related to the
WBC and fever may 2) Monitor
evidenced by dilated
temperature reflect temperature at
least 4hourly
normal vital cervix and
developing
3-Take signs and open uterine
sepsis
medications as absence of vessels
prescribed 3) To prevent signs and
3) Provide pt
infection. symptoms of
4-Pt takes education
infection
adequate 4) To perineal
(normal
amount of eliminate and hygiene (wipe
WBC, and
fluid. prevent perineal area
temperature),
infection. from front to
take
back after
5) Proper medications
avoiding)
nutrition and a as prescribed
balanced diet 4) Administer and the Pt
support the antibiotic will be able
immune medication as to takes
systems’ prescribe. adequate
responsiveness amount of
and enhance 5) Encourage p
fluid.
the health of tot intake of
all the body’s protein-rich and
tissues. calorie-rich
foods and
6) To maintain encourage a
 fluid balance balanced diet.
6) Encourage pt
to take adequate
amount of fluid

Assessment Nursing Goal Nursing Rational Evaluation

diagnosis Interventions
Sub data: Decreased After of 1- Assess vital 1- Blood The goal was
-Headache Cardiac nursing signs pressure met: by time
-Vision Output intervention, especially BP may discharge,
changes related to the patient be and pulse. fluctuate and - The
-Nausea decreased able to: 2- Institute spike patient’s
-epigastric venous - Have control bedrest with quickly; blood
pain return as blood pressure patient in monitor for pressure is
manifested: at or lateral changes and control
Obj data: BP: below140/90 position. elevations. (135/8276mm
BP: 141/76mm - Verbalize 3- Weigh the 2- To Hg)
141/76mm Hg relive or patient improves
Hg -pitting control of 4- Assess for venous - Verbalized
-Pitting edema headache and edema return, relieved and
edema Headache pain. 5- Instruct in cardiac controlled of
-Less urine -Vision relaxation output. headache and
output changes - techniques, 3- Fluid pain.
-Nausea Understanding and guided retention
-epigastric about her imagery. and possible -The patient
pain condition and 6- Administer IV progression was able to
-Less urine acknowledge fluids and of disease understanding
output about the medications as and about her
factors that appropriate. impaired condition and
affect in blood 7- Implement renal acknowledge
pressure. dietary function about the
sodium, fat, 4- Pitting factors that
and edema can affect in
cholesterol be a blood
restrictions as significant pressure.
indicated. sign of
decreased
cardiac
output.
5-Can
reduce
stressful
stimuli,
produce
calming
effect,
thereby
reduce
blood
pressure.
6- To reduce
blood
pressure and
relieve pain.
7- These
restrictions
 can help
manage
fluid
retention
and with
associated
hypertensive
response,
which
decrease
cardiac
workload.

Evaluation Rational Nursing Goal Nursing Assessme

Interventions Diagnosis nt
The short 1. To establish 1. Assess blood Short goal: Altered Sub:
goal was data glucose level After 8 hours blood Worried
meet: 2. To initiate before meal of nursing glucose about her
After 8 hours immediate 2. Teach pt. intervention level condition
of nursing intervention signs& the patient related to
intervention 3. Nonadherence symptoms of will be able GDM. Obj:
the patient to dietary hyperglycemia. to understand FBS:5.7
was able to guidelines. 3. Health teaching the condition mmol/L
understand 4. To help pt about proper of her blood T35.5, Bp:
the condition understand diet of patients glucose level 141/76mm
of her blood GDM with gestational and what is Hg, p:
glucose level 5. To promote pt diabetes the factors 61/min.
and what is compliance. mellitus and the that may lead
the factors importance of to unstable
that may lead following diet. glucose and
to unstable 4. Assess pt. demonstrate
glucose and know about her her
demonstrate condition. understandin
her 5. Teach pt the g of the
understandin importance of importance of
g of the medication. breastfeeding
importance of by
breastfeeding breastfeeding
by when the
breastfeeding infant is
when the hungry.
infant is
hungry. Long goal:
Pt reaches
Long term normal blood
was met: by glucose level
time by discharge.
discharge, the
patient
reaches
normal blood
glucose level.

Name, Age, Family nursing Goals/Objectives Implementations Evaluation

Sex diagnosis
 - Create an environment of trust by
Goal: listening to family concerns and The Goal was
Deficit After nursing being available for questions. met,
All family Knowledge intervention, the After health
members among family family will have - Work with family members in education session
members adequate knowledge setting mutual goals for learning, and explanation,
regarding the about the chronic participate in the planning and family being with
underlying disease, healthy diet promote cooperation with the adequate
disease, healthy and preventive principles learned. knowledge about
diet and measures of diabetes healthy diet and
preventive mellitus and -Provide oral and written preventive
measures for hypertension. information about these diseases measures of
diabetes - Select a variety of teaching diabetes mellitus
mellitus and Objectives: strategies and plans by and hypertension
hypertension After 15 minutes of demonstrate needed skills and complications.
manifested by teaching session the have family do return
the family family members will demonstration of HGT.
members asked be able to:
me questions - Encourage the family to ask
- understand and
and need for questions about the diseases and
know the meaning
more health treatment
of diseases,
education &
symptoms, and
explanations - Educate them about the signs &
prevention.
about DM and symptoms of complications.
HTN. - follow appropriate
diets for these - Discuss essential elements of
diseases. health teaching plan like healthy
- To understand how diet and what foods to be
exercise helps to maintained and what food to be
prevent these avoided.

Evaluation/ Observation
(2 Marks)
The goal was meet:
-The Client was able to understand
the condition of her blood glucose
level and what are the factors that
may lead to unstable glucose.
-Client Blood Glucose level was
decreased and maintained at
normal levels
diseases
Implementation
(3 Marks)
1.Teach the client how to
perform home glucose
monitoring.
2. Encourage client to check
blood glucose level before
meals and at bedtime.
3. Teach client signs &
symptoms of hypoglycemia.
3. Health teaching about
proper diet of clients with
diabetes mellitus and the
importance of following a diet.
4.Discuss the importance of
- Provides knowledge base from
which patient can make informed
lifestyle choices and awareness of
importance of dietary control.
Goals/ Objectives Family Nursing Diagnosis (3
Nam
(2 Marks) Marks)
Risc for unstable Blood Glucose Raya, 70yrs,
Goal: level, related to Insulin Resistance
or decreased production or
-The Client will be able to utilisation of
understand the condition of her Insulin.
blood glucose level and what are
the factors that may lead to
unstable glucose.
-Client Blood Glucose level will
be decreased and maintained at
normal levels
balancing exercise with food
intake.
5.Educate the patient about the
proper ways of taking
prescribed medications.
6. Teach client the importance
of medication.
Objectives:
After 15 minutes of teaching
session the family members will be
able to:
- know how to perform home
glucose monitoring.
-what are the signs & symptoms of
hypoglycemia.
-Importance of balancing exercise
with food intake.
 Assessment Nursing Goals Nursing Intervention Rationale Evaluation
Diagnosis

SUBJECTIVE DATA: Imbalance nutrition; Short-term 1- Assess nutritional status: 1- Baseline data allow for Goals met:
less than body goal: Client’s monitoring of changes and -Patient maintains
- Anorexia. requirement related appetite and *weight changes. evaluating effectiveness of adequate nutritional
to malnutrition s weight will *laboratory values. NI. intake as evidenced by
- Tired.
- Little interest in manifested by increase 2- Past and present dietary being free of signs of
patient verbalized within 2 2- Assess patient’s nutritional patterns are considered in malnutrition.
cooking or eating. dietary patterns:
dizziness, anorexia, weeks of planning meals.
- No nausea and
easily getting tired, implementing ● Diet history. -The patient
vomiting.
reduction in weight NI from 43.1 3- Information about other demonstrate
- Reduction of weight to 43.1 kg and BMI= kg to 47.5 kg. progressive weight
● Food preferences. factors that may be
from 53.5 kg to 43.1 16.8 under normal, gain toward goals that
eliminated to promote
kg. thin, looks pale Long-term increases 14 kg within
3- Assess factor contributing to adequate dietary intake.
- triceps thickness= goal: client 2months.
OBJECTIVE DATA: 11mm and abnormal will maintain altered nutritional intake:
lab investigations normal body 4- Encourage increased -patient maintains
● Anorexia, nausea, vomiting. dietary intake.
- Weight= 43 .1 kg test: weight that normal dietary and
- BMI= 16.8. Albumin=2.9 g/dl, increases to ● Depression. fluid intake.
- Serum 58.9kg within 5- Allows monitoring of
- Triceps thickness=
cholesterol= 2 months. fluids and nutritional
11mm. 4- Provide patient’s food
130mg/dl status.
- Skin is pale. preferences.
and HB=
- Thin. 9g/dl 5- Weigh patient daily. 6- Complete protein is
- Albumin=2.9 g/dl. provided for positive
- Serum cholesterol= 6- Promote intake of high
nitrogen balance needed
biologic value protein foods:
130mg/dl. for growth and healing.
eggs, dairy products, meat.
- HB= 9g/dl