Assessment Explanation of the Objective Nursing Intervention Rationale Evaluation

Problem
Subjective Data: Intake of nutrients STO: Dx: STO: Goal Met
“Paunti unti lng syang insufficient to meet After 3 hours of Assess for signs of malnutrition Insufficient nutrition may cause After 3 hours of
uminon tapos ang liit metabolic needs. intervention the child and such as poor skin turgor, and physical signs of poor nutritional intervention the child
ng kinakain nya” as significant other will: muscle wasting intake and significant other
verbalize by the (NANDA 2021) -Demonstrate will:
mother understanding of Assess eating patterns, food -demonstrate
nutritional principles and preferences and food habits To create a baseline of the understanding of
Objective Data: food requirement patient's nutritional status and nutritional principles
Assess nutritional needs preferences and food requirement
Poor skin turgor
To determine nursing care goals
Dry Skin Monitor and record the amount,
LTO: color, consistency and presence Characteristics of vomitus and LTO: Goal partially
Sunken eyes After 1 week of nursing of occult blood in emesis and stools provide clues to nutrient met
intervention: stools absorption After 1 week of nursing
Abnormal BMI with intervention:
Ht: 84 cm and at -Patient will have Monitor vital signs
weight: 10 kg adequate hydration
Provide baseline data -Patient will have
-Child will achieve and adequate hydration
maintain a healthy weight Obtain the patient's height and
for age and height weight These measures patients
nutritional needs -Child will achieve and
maintain a healthy
weight for age and
Tx: height
Administer anti-diarrhea
medication as prescribed To stop or slow down the diarrhea
To ensure adequate fluid and
Provide parenteral fluids as electrolyte levels
ordered

To determine ability and readiness

of intestinal tract to handle
Auscultate presence and digestive process
character of bowel sounds

Oral hygiene improves taste of

food

Assist and provide oral care

before and after meals and at
bedtime
This will reduce feeling of fullness
and the risk of vomiting
Edx:
Emphasize to SO to give patient A well balanced diet provides
small but frequent meals essential nutrient that support
optimal physiological functioning
Emphasize to SO the importance
of well-balanced, nutritious
intake Understanding the rationale
behind dietary recommendations
allows SO to make informed
decisions and contribute to the
patient's overall health and
Provide information regarding recovery
patient nutritional need to SO