Alabang-Zapote Road, Pamplona 3, Las Pias City, Metro Manila 1740, PHILIPPINES

www.perpetualdalta.edu.ph +63(02) 871-06-39

College of Nursing

ASSESSMENT NURSING PLANNING AND

NURSING INTERVENTION RATIONALE EVALUATION
CUES DIAGNOSIS OUTCOME
SUBJECTIVE: Imbalanced After 4 hours of Independent: Goal met:
Ayoko ng kumain, Nutrition: less nursing intervention, Ascertain understanding of To determine informational need After 4 hours of nursing
busog na ako. as than body the patient will be individual nutritional needs. of the client. intervention, the patient
verbalized by the requirements able to: was able to verbalize
patient. related to loss of Verbalize Evaluate impact of cultural, May affect food choices. understanding of
appetite due to understanding of ethnic, or religious causative factors when
aging causative factors desires/influences. known necessary
OBJECTIVE: when known and interventions.
Loss of appetite necessary Prevent minimize unpleasant May have negative effect in the
Weakness interventions. odors. appetite. Goal not met:
After 1 week of nursing
After 1 week of intervention, the patient
Demonstrate clients ability to
nursing intervention, All factors that can affect was not able to
chew, swallow, and taste food.
the patient will be ingestion and digestion of demonstrate progressive
able to: nutrients. weight gain toward goal
Dependent:
Demonstrate and demonstrate
Administer Regeron-e, K-lyte,
progressive To provide nutritional support. behaviors, lifestyle
and Aminovita as ordered by changes to
weight gain
the physician. regain/maintain weight.
toward goal.
Demonstrate
Collaborative:
behaviors,
Cooperate with the family to To facilitate balanced foods.
lifestyle changes
serve foods that are liked by
to regain/maintain
the patients and at the same
weight.
time highly rich in nutrients.

ASSESSMENT NURSING PLANNING AND

NURSING INTERVENTION RATIONALE EVALUATION
CUES DIAGNOSIS OUTCOME
 Alabang-Zapote Road, Pamplona 3, Las Pias City, Metro Manila 1740, PHILIPPINES
www.perpetualdalta.edu.ph +63(02) 871-06-39

College of Nursing
SUBJECTIVE: Decreased After 7 hours of Independent: Goal met:
Nahihilo ako. As cardiac output nursing intervention, Monitor BP every 1-2 hours, Changes in BP may indicate After 7 hours of nursing
verbalized by the the patient will have or every 5 minutes during changes in patient status requiring intervention, the patient
patient. no elevation in blood active titration of vasoactive prompt attention. had no elevation in blood
pressure above drugs. pressure above normal
normal limits and limits and maintained a
OBJECTIVE: will maintain blood Suggest frequent position It may decrease peripheral venous blood pressure within
Decreased pressure within changes. pooling that may be potentiated by acceptable limits.
cardiac output acceptable limits. vasodilators and prolonged sitting
Lethargic or standing.
Vital signs taken
as follows: Encourage patient to decrease Caffeine is a cardiac stimulant and
T: 36.4 intake of caffeine, cola, and may adversely affect cardiac
PR: 75 bpm chocolates. function.
RR: 21 cpm
BP: 180/100 Observe skin color, Peripheral vasoconstriction may
temperature, capillary refill result in pale, cool, clammy skin,
time and diaphoresis. with prolonged capillary refill
time.

Instruct client & family on Restrictions can assist with

fluid and diet requirements decrease in fluid retention and
and restrictions of sodium. hypertension, thereby improving
cardiac output.

Dependent:
Administer medicines as To promote wellness.
prescribed by the physician.