CUES

PROBLEM

SCIENTIFIC REASON Nutritional deficiencies primarily affect gastrointestinal disorder or due to the procedures prior and after surgeries.

DESIRED OUTCOME Short term goal: After 6 hours of nursing interventions client will verbalize understanding of causative factors and necessary interventions to promote optimum nutrition.

INTERVENTION/ RATIONALE Ascertain understanding of individual nutritional needs. To determine informational needs of client. Assess weight, measure or calculate body fat and muscle mass and other anthropometric measurements. To establish baseline parameters. Observe for absence of subcutaneous fat and muscle wasting, hair loss, fissuring of nail, delayed healing of wounds, gum bleeding or swollen abdomen. Indicates proteinenergy

EVALUATION STANDARD CRITERIA

Subjective: Puro liquids lang ang kinakain ko. As verbalized by the patient.

Risk for imbalanced nutrition: less than body requirement related to Objective: restriction of residue Presence of containing stoma in the foods. left lower quadrant of the abdomen With NGT inserted Limited ROM

(Source: http://www.scribd Long term goal: .com/doc/101291 785/8NCP-s-for- After 1-2 days of colostomy) nursing interventions client will be able to demonstrate behaviors, lifestyle changes to regain and maintain appropriate nutrition intake.

Client has a Client proper demonstrates nutritional behaviors and status. lifestyle changes that regains and maintains appropriate nutrition intake.

malnutrition. Auscultate bowel sounds. Note characteristic of stool (color, amount, frequency) Provide diet modification as indicated. (formula tube feedings, parenteral nutrition infusion) Instruct client to avoid foods that causes intolerance or increase gastric motility according to individual needs. Limit fiber or bulk, if indicated. Because it may lead to early satiety. Assist with or provide oral care before and after meals and at bedtime. Promote adequate and timely fluid intake.

 Weight regular and graph results. To monitor effectiveness of efforts and dietary plans. Evaluate total daily food intake. Obtain diary or calorie intake, patterns and times of eating. To reveal possible cause of malnutrition and changes that could be made in clients intake.