ASSESSMENT NURSING SCIENTIFIC OBJECTIVES INTERVENTIONS EVALUATION

DIAGNOSIS EXPLANATION AND RATIONALE

Subjective: Imbalanced Imbalanced Short Term: 1. Determine

nutrition, less nutrition, less than After 3 hours of lifestyle factors
“Kasi po walang lasa than body body requirements effective nursing that may affect
mga pinapakain sakin requirements can be defined as interventions, the weight because
kaya ayaw ko na related to the intake of patient will be able socioeconomic
kumain.” insufficient nutrients to verbalize resources,
interest in food insufficient to meet understanding of amount of
Objective: given. metabolic needs. causative factors money
Patient manifested: when know and available for
● 20% less than The patient necessary purchasing
ideal weight manifested a interventions. food are all
● Patient’s weight 20% less factors that
weight 24.6 kg than the ideal may impact
● Abdominal weight for his age. food choice and
pain with With acute intake.
burning glomerulonephritis, 2. Assess weight;
● Vital signs the diet of the measure
taken as patient is restricted muscle mass,
follows to low salt diets. or calculate
○ T: 35.8 Therefore, the body fat by
○ PR: 71 patient states that means of
bpm his food tastes anthropometric
○ RR:21 bland and does not measurements
cpm want to eat it. and growth
○ BP: scales to
110/80 identify
mmHg deviations from
● Patient may the norm and to
manifest: establish
● Weight loss baseline
with adequate parameters
food intake 3. Observe for
● Electrolyte absences of
imbalances subcutaneous
● Pale mucous fat and muscle
membranes wasting, loss of
● Hyperactive har, fissuring of
bowel sounds fingernails,
● diarrhea delayed
healing, gum
bleeding,
swollen
abdomen which
indicate
protein-energy
malnutrition
4. Evaluate total
daily food
intake. Obtain
diary of calorie
intake,
patterns, and
times of eating
to reveal
possible cause
of malnutrition
and changes
that could be
made in
patient’s intake
5. Promote
adequate and
timely fluid
intake. Limit
fluids 1 hour
prior to meal to
reduce
possibility of
 early satiety
6. Use flavoring
agents( e.g.,
lemon and
herbs) if salt is
restricted to
enhance food
satisfaction and
stimulate
appetite
7. Collaborate
with
interdisciplinary
team to set
nutritional goals
when patient
has specific
dietary needs,
malnutrition is
profound, or
long-term
feeding
problems exist
8. Recommend
and support
hospitalization
for controlled
environment in
severe
malnutrition or
life-threatening
situations
9. Administer
nifedipine 10mg
PRN for BP>
120/80 mmHg
 as prescribed
10. Administer
furosemide
30mg I.V. q 12
as prescribed
to reduce extra
fluid in the body

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES INTERVENTIONS EVALUATION

DIAGNOSIS EXPLANATION AND RATIONALE

Subjective: Impaired tissue Impaired tissue Short Term: 1. Evaluate skin

integrity related integrity can be After 3 hours of and mucous
Objective: to excessive fluid defined as damage effective nursing membranes for
Patient manifested: volume as to the mucous interventions, the hydration
● Facial edema evidenced by membrane, patient will be able status,note
● Bipedal facial and cornea, to verbalize presence and
edema bipedal edema. integumentary understanding of degree of
● Vital signs system, muscular condition and edema ( 1+ to
taken as fascia, muscle,, causative or risk 4+), urine
follows tendon, bone factors. characteristics
○ T: 35.8 cartilage, joint and output to
○ PR: 71 capsule, and/or determine
bpm ligament. presence of
○ RR:21 circulatory or
cpm With Acute metabolic
○ BP: glomerulonephritis, imbalances
110/80 the part of the resulting in fluid
mmHg kidneys that filters deficit or
● Patient may blood is injured. overload that
manifest: When the kidney is can adversely
● Damaged or injured, it cannot affect cell or
destroyed excrete wastes and tissue health
tissue extra fluid in the and organ
● Local pain body properly. function
● Skin and Thus, resulting in 2. Determine
tissue color edema or puffiness nutritional
changes in the face or other statues to
● Altered parts of the body assess impact
sensation at Source: of malnutrition
site of tissue https://www.kidney. on situation.
impairment org/atoz/content/gl 3. Note color,
● Affected area omerul texture, turgor
is tender and note
presence,
location, and
degree of
edema for
comparative
baseline.
4. Provide or
encourage
 optimum
nutrition to
promote tissue
health/healing
and adequate
hydration to
reduce and
replenish
cellular water
loss and
enhance
circulation.
5. Promote early
and ongoing
mobility. Assist
with or
encourage
position
changes, active
or passive and
assistive
exercises in
immobile
patient to
promote
circulation and
prevent
excessive
tissue pressure.
6. Emphasize
need for
adequate
nutritional and
fluid intake to
optimize
healing
 potential.
7. Collaborate
with other
health care
providers as
indicated to
assist with
developing plan
of care for
problematic, or
potentially
serious wounds
8. Review medical
regiment to
facilitate tissue
healing and
prevent
complications
associated with
lack of
knowledge
about
maintaining
tissue integrity
9. Administer
furosemide
30mg I.V. q 12
as prescribed
to reduce extra
fluid in the body
ASSESSMENT NURSING SCIENTIFIC OBJECTIVES INTERVENTIONS EVALUATION
DIAGNOSIS EXPLANATION AND RATIONALE

Subjective: Ineffective Impaired tissue Short Term: 1. Monitor level of

protection related integrity can be After 2 hours of consciousness
Objective: to abnormal defined as the effective nursing and behavior
Patient manifested: blood profile as decrease in the interventions, the because low
● Hematocrit evidenced by ability to guard self patient will be able blood profiles
level 32.9% lowered from internal or to verbalize may cause
(35.0-39.0) hematocrit and external threats understanding of cerebral
● Hemoglobin hemoglobin such as illness or interventions to help hypoxia
level 11.5g/dL levels. injury. increase hematocrit manifested by
(12.0-16.0) and hemoglobin changes in
● Vital signs With Acute levels such as iron orientation and
taken as glomerulonephritis, supplementation behavioral
follows the part of the and intake of certain responses.
○ T: 35.8 kidneys that filters foods. 2. Encourage
○ PR: 71 blood is injured. intake of certain
bpm Healthy kidneys foods such as
○ RR:21 produce meat, dark
 cpm erythropoietin. If green and leafy
○ BP: kidneys are vegetables,
110/80 damaged or beans, and
mmHg injured, they do not foods rich in
● Patient may make enough vitamin C like
manifest: erythropoietin, citrus fruits and
● Deficient which deprives the tomatoes to
immunity body from making increase
● Impaired sufficient amounts hematocrit level
healing of RBCs. through natural
● Dyspnea Therefore, when means
● Restlessness the blood has fever 3. Encourage
● Immobility RBCs, the body is patient to
deprived of the exercise
oxygen it needs. regularly to
help the body
produce red
blood cells.
4. Instruct to take
Source: vitamins and
https://www.niddk. minerals to
nih.gov/health- keep the body
information/kidney- in good general
disease/chronic- health as well
kidney-disease- as help aid in
ckd/anemia the absorption
of iron in the
body.
5. Instruct patient
to avoid certain
foods or take in
small amounts
such as coffee,
tea, pasta
because they
can prevent
 absorption of
iron.
6. Encourage
patient to
consuming
foods like
spinach, beans,
lentils, bok
choy,
asparagus to
increase folic
acid which aids
in the
production of
hemoglobin
7. Monitor
laboratory
studies
especially,
RBCs Hb and
Hct. to detect if
levels decrease
further.
8. Administer
fresh blood,
PRBCs as
indicated
because this
may be
necessary if
patient is
symptomatic
with anemia