1. The nursing diagnosis for this patient is imbalanced nutrition related to lack of appetite as evidenced by weight loss.
2. The goal is for the patient to gain weight to within 10% of their ideal body weight over 2 months with nursing interventions.
3. Interventions include assessing nutritional status, educating on a healthy diet, planning meals with the patient, and addressing factors impacting appetite such as environment and positioning. Evaluation will assess if the patient reached the weight goal.
1. The nursing diagnosis for this patient is imbalanced nutrition related to lack of appetite as evidenced by weight loss.
2. The goal is for the patient to gain weight to within 10% of their ideal body weight over 2 months with nursing interventions.
3. Interventions include assessing nutritional status, educating on a healthy diet, planning meals with the patient, and addressing factors impacting appetite such as environment and positioning. Evaluation will assess if the patient reached the weight goal.
1. The nursing diagnosis for this patient is imbalanced nutrition related to lack of appetite as evidenced by weight loss.
2. The goal is for the patient to gain weight to within 10% of their ideal body weight over 2 months with nursing interventions.
3. Interventions include assessing nutritional status, educating on a healthy diet, planning meals with the patient, and addressing factors impacting appetite such as environment and positioning. Evaluation will assess if the patient reached the weight goal.
1. The nursing diagnosis for this patient is imbalanced nutrition related to lack of appetite as evidenced by weight loss.
2. The goal is for the patient to gain weight to within 10% of their ideal body weight over 2 months with nursing interventions.
3. Interventions include assessing nutritional status, educating on a healthy diet, planning meals with the patient, and addressing factors impacting appetite such as environment and positioning. Evaluation will assess if the patient reached the weight goal.
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Cues Nursing Inference Goal and Interventions Rationale Evaluation
Diagnosis Objectives Subjective: Imbalanced Adequate Goal He loses Nutrition: nutrition is his Less than necessary to meet By November 15, After 2 months weight body the body’s 2010 the client will of nursing during his requirements demands. weigh within 10% intervention, stay in related to lack Nutritional status of ideal body was the client the of appetite as can be affected by weight. able to reach hospital manifested by disease or injury 10% of his ideal because weight loss states (e.g., Objectives body weight? during gastrointestinal () yes ()no the start [GI] of his malabsorption, 1) After 2hrs of 1. Assess the weight 1. Provides baseline illness, he cancer, burns); nursing of the client. data about the client. lost his physical factors intervention appetite. (e.g., muscle , the patient 2. Determine 2. To assess the usual “Grabe, weakness, poor or caregiver client’s nutritional food that she eats sobra na dentition, activity will history. even before nga ang intolerance, pain, verbalize pregnancy. ipinayat substance abuse); and ko eh, social factors (e.g., demonstrat hindi lack of financial e selection 3. Determine the 3. Psychological naman resources to of foods or client’s factors towards ako obtain nutritious meals that attitude towards eating may ganito foods); or will achieve eating. affect one person’s kapayat psychological a cessation appetite and also to dati para factors (e.g., of weight know the client’s na nga depression, loss. eating habits. akong boredom). During buto’t times of illness
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balat”, (e.g., trauma,
patient surgery, sepsis, verbalize burns), adequate 4. Education provides d. nutrition plays an 4. Educate the “Sino ba important role in client ample information naman healing and regarding the that the client may kasi ang recovery. Cultural importance of not be aware of, makakaka and religious eating hence leading to the in ng factors strongly healthy foods and kind of eating habits maayos affect the food it’s benefits to his and diet she is dito diba, habits of patients. body. following. syempre Women exhibit a iba yung higher incidence 5. Educate the 5. For the client to be pagkain of voluntary client aware of the needed dito restriction of food regarding the nutrients by her body kumpara intake secondary vitamins to nourish herself sa to anorexia, and minerals that and her baby kinakain bulimia, and self- are throughout the mo sa constructed fad important such as pregnancy. Also, bahay”, dieting. Patients vitamin C, iron, giving sources of patient who are elderly calcium, and these nutrients helps added. likewise protein; the client to easier When he experience and the sources of familiarize herself as gets problems in these to what foods she wounded, nutrition related nutrients. may include in her that wound to lack of financial diet. doesn’t resources, heal easily. cognitive 6. Involving the client impairments 6. Plan with the to his plan of care Objective: causing them to client his gives the client the Small forget to eat, desired meals. feeling of independence. It
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body physical limitations
frame that interfere with also personalizes the Weak preparing food, plan of care since the looking deterioration of client does make the Pale their sense of choices in some conjuncti taste and smell, aspects of the plan. va and reduction of mucous gastric secretion 7. Suggest ways 7. A pleasant membran that accompanies that may environment gives e aging and assist the client in the client a relaxed Dry skin interferes with eating feeling and will not Evidence digestion, and a. Ensure pleasant spoil her appetite. of lack of social isolation and environment. And proper available boredom that b. Facilitate proper positioning reduces food cause a lack of positioning the risk of aspiration interest in eating. and heartburn. Measurem 8. Instruct the ent: client to 8. Caffeinated Weight: avoid caffeinated beverages may Height: beverages. decrease the BMI: appetite and will make the client feel full easily.
9. Instruct the 9. Junk foods have
client to empty calories that avoid junk foods. provide no nutritional help to the client. The weight gain that these foods may bring is of no good
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for the client and her
baby. 10. Instruct the client to 10.Too much food follow the intake prescribed is not good for the number of servings body. Too much of the meals included weight gain, which is in his out of the expected, meal plan. may bring about complications, such 11.Encourage the as client to diabetes mellitus. maintain the intake of 11.To provide the healthy foods nourishment to the needed by his body client that keeps both to achieve ideal of body weight. them healthy.
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Far Eastern University
Nicanor Reyes, St., Sampaloc, Manila
Nursing Care Plan
Submitted by: Sosing Charles Joseph C. Group 134
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Name: Gerald Age: 3 Years Old Current Diagnosis: Imperforate Anus Nursing Care Plan Cues/Clues Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation