ASSESSMEN DIAGNOSIS INFEREN GOAL INTERVENTIONS RATIONALE EVALUATION

T CE
SUBJECTIVE: Imbalanced Intake of After 5 days of Give frequent oral care, Noxious tastes, smells, and sight After 5 days of
nutrition: less nutrients nursing remove expectorated are prime deterrents to appetite nursing
“Ang laki ng than body insufficien interventions, secretions promptly, provide and can produce nausea and interventions, the
pinayat nya requirements t to meet the client will specific container for disposal vomiting with increased goal was met. The
dahil ayw related to metabolic display of secretions and tissues. respiratory difficulty. client displayed
kumain”, as sputum needs progressive progressive weight
verbalized by production. weight gain as Encourage a rest period of 1 Helps reduce fatigue during gain as evidenced
the aunt. evidenced by: hour before and after meals. mealtime, and provides by:
Provide frequent small opportunity to increased
OBJECTIVE: EXPECTED feelings. respiratory total caloric intake. EXPECTED
OUTCOMES: OUTCOMES:
Weight loss - increase of 3 Avoid gas-producing foods Can produce abdominal - increased of 3 lbs
Loss of lbs in weight and carbonated beverages. distention, which hampers in weight
muscle mass abdominal breathing and
Poor muscle SHORT TERM: diaphragmatic movement and can SHORT TERM:
tone increase dyspnea.
Lack of After 2 hours Avoid very hot or very cold After 2 hours of
interest in of nursing foods. Extremes in temperature can nursing
food interventions, precipitate/ aggravate coughing interventions,the
the guardian spasms. goal was met. The
will verbalize Weight as indicated. guardian verbalized
understanding Useful in determining caloric understanding of
of needs, setting weight goal, and interventions to
interventions evaluating adequancy of increase body
to increase nutritional plan. note: weight loss weight of the baby
body weight of may continue initially despite as evidenced by:
the baby as Consult dietitian to provide adequate intake, as edema is
evidenced by: easily digested, nutritionally resolving EXPECTED
balanced meals by OUTCOMES:
EXPECTED appropriate means; e.g, oral, Method of feeding and caloric -verbalizing 3
OUTCOMES: supplemental/ tube feedings, requirements are based on exampled
-verbalizing 3 parenteral nutrition. (Refer to individual needs to provide interventions
exampled CP: Total Nutrional Support: maximal nutrients with minimal
interventions Parenteral/ Enteral feeding.) energy expenditure.

Administer supplemental
oxygen during meals as
indicated.
Decrease dyspnea and increases
energy for eating enhancing
intake.