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Assessment Explanation of the Problem Objectives Nursing Interventions Rationale Evaluation

S>Di siya makakain nang


maayos at nanghihina
paas verbalized by the
significant other.

O>Weight loss note
>Documented inadequate
caloric intake
>Easy fatigability observed
>Reported altered taste
sensation
> Weakness of muscle
required for mastication
> Aphagia noted


Nursing Diagnosis:
Imbalance nutrition: less
than body requirements
r/t insufficient nutrition
intake secondary to
decreased taste sensation

Since the client is unable to
eat using mechanical
mastication, she is required
to have oral feedings via
nasogastric tubing and
since she is a geriatric
client, her taste buds
become less effective. Due
to the existence of the NGT
tube an unfamiliar or
unpalatable food is
entering the clients
system. The content of the
food is not enough to
supply the metabolic needs
leading to decreased
strength and stamina.
Thus, intake of insufficient
nutrition leads to
imbalance nutrition less
than body requirements.

STO: After 2-3 hours of
rendering effective nursing
intervention the client will
be able to demonstrate the
following:
a)Importance of nutritional
intake
b)Importance of
maintaining body weight
c)Verbalize understanding
of causative factors when
known and necessary
interventions


LTO: After 2-3 days of
rendering effective nursing
intervention the client will
be able to understood the
following:
a)Right amount of calorie
intake
b)Progressive weight gain
toward goal
c)To take vitamins regularly
Dx:
>Assess body mass index



>Asses nutritional intake


>Auscultation bowel
sounds.




Tx:
>Assist in performing oral
hygiene

>Administer medications as
ordered

>Assist in NGT feeding



Edx:
>Encourage the significant
others to feed nutritious
foods


>Instruct to warm the
feeding before

>To provide a general
assessment of a persons
body composition

>To know the intake of
essential nutrients

> Bowel sounds are
decreased or increased
indicates a disturbance in
digestive function



>Bad breath odor can
reduce appetite.

>to prevent complications


>To satisfy hunger and
increase the nutritional
intake


>To increase influenced of
persons taste about the
importance of nutrition of
the body

>to prevent
gastrointestinal upset
STO:GOAL MET if
After 2-3 hours of
rendering effective
nursing intervention the
client was able to
demonstrate the
following:
a)Importance of
nutritional intake
b)Importance of
maintaining body
weight
c) Verbalize
understanding of
causative factors when
known and necessary
interventions




LTO:After 2-3 days of
rendering effective
nursing intervention the
client will be able to
understood the
following:
a)Right amount of
calorie intake
b) Progressive weight
gain toward goal
c)To take vitamins
regularly
administering

>Instruct and emphasize
the importance of hand
hygiene


>To prevent
microorganisms from
entering the body through
NGT feeding