Name of Pt: Bacaron, Anacleta

Diagnosis: Multiodular non toxic goiter

Time/Date Assessment Nsg. Diagnosis Goal of Care Nsg. Interventions Evaluation
August 29,
2014

7-3 shift
Subjective: medyo lisod
mulunok pero makaya man
nako mukaon basta lugaw






Objective:
BP: 120/80, temp: 36.6 C,
pulse: 81, RR: 18, with post
of dressing @ anterior
neck dry and intact.

Imbalanced
Nutrition: less than
body requirements
r/t inability of clients
to enter or swallow
food.
Within 8 hours of
nursing intervention,
the patient will be
able to ingest foods
in order to restore
optimum nutritional
status, to meet the
body requirements
and to promote
health.
1.) Monitor VS.

2.) Monitor
Intake and
Output.

3.) Promote
adequate fluid
intake.

4.) Determine
and evaluate
the ability to
chew and
swallow food.

5.) 6.) Promote
rest

6.) 7.) Administer
anti emetic
drugs or as
ordered by
the physician
before meal.
Within 8 hours of
nursing intervention,
the patient displayed
good appetite but
still vomited even
taking anti-emetic
drug.