Professional Documents
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Objective: Imbalance Intake of nutrients Short Term: 1.Established NPI 1.To gain client’s Short Term:
-weight loss (from Nutrition: Less insufficient to After 6 hours of confidence. Served foods are
69kg-58kg) than Body Weight meet metabolic nursing 2.Assess weight, 2.To establish tolerated and
related to self- needs. intervention, the BMI. baseline verbalized
-pale in overall imposed dietary patient will be parameters. understanding of
appearance restrictions, lack Source: able to verbalize 3.Encourage 3.To meet other
Weakness
of information Nurse’s Pocket understanding of several small nutritional needs. interventions to
and poor choice Guide by M. causative factors nutritious meals. 4.To reveal attain balance
-decrease RBC
(4.40x1058kg)
of kind of foods as Doenges when known and possible cause of nutrition.
manifested by the necessary 4.Evaluate total imbalance and
-pale in overall weight loss. Pale interventions. daily food intake. changes that Long Term:
appearance in overall could be made in Lifestyle changes
Weakness appearance. Long Term: 5.Emphasize client’s intake. are demonstrated
The patient will be importance of 5.Compliance to and actualized to
-decrease RBC able to well-balanced, realistic diet maintain healthy
(4.40x1013/L) demonstrate nutritious intake. modifications. balance.
behaviours, Provide
-no rice for the past
lifestyle changes information
6 months during
to maintain health regarding
dinner.
and appropriate individual
-loose biceps and weight. nutritional needs
triceps skin folds. and ways to meet
these needs
within financial
constraints.
Cues Nursing Diagnosis Scientific Reason Planning Intervention Rationale Evaluation
Objective: Imbalance Nutrition: Less Intake of nutrients Short Term: 1.Established NPI 1.To gain client’s Short Term:
-weight loss (from 69kg- than Body Weight related insufficient to meet After 6 hours of nursing confidence. Served foods are tolerated
58kg) to self-imposed dietary metabolic needs. intervention, the patient 2.Assess weight, BMI. 2.To establish baseline and verbalized
restrictions, lack of will be able to verbalize parameters. understanding of other
-pale in overall appearance information and poor Source: understanding of causative 3.Encourage several small 3.To meet nutritional interventions to attain
Weakness choice of kind of foods as Nurse’s Pocket Guide by M. factors when known and nutritious meals. needs. balance nutrition.
manifested by weight loss. Doenges the necessary
-decrease RBC Pale in overall appearance. interventions. 4.Evaluate total daily food 4.To reveal possible cause Long Term:
(4.40x1058kg) intake. of imbalance and changes Lifestyle changes are
Long Term: that could be made in demonstrated and
-pale in overall appearance The patient will be able to client’s intake. actualized to maintain
Weakness demonstrate behaviours, healthy balance.
lifestyle changes to
-decrease RBC maintain health and
(4.40x1013/L) appropriate weight. 5.Emphasize importance of 5.Compliance to realistic
well-balanced, nutritious diet modifications.
-no rice for the past 6 intake. Provide information
months during dinner. regarding individual
nutritional needs and ways
-loose biceps and triceps to meet these needs within
skin folds. financial constraints.
Cues Nursing Diagnosis Scientific Reason Planning Intervention Rationale Evaluation
Subjective: Anxiety (severe) related to Vague uneasy feeling of Short Term: 1.Established NPI 1.To alleviate fear and to Short Term:
-insomia situational crisis and stress discomfort of dread after shift, the patient will gain confidence. Goal met
AMB too much talking; accompanied by an appear relaxed and report 2.Monitor VS The patient appeared
-restlessness restlessness secondary to autonomic response (the anxiety is reduced to a 2.To identify physical relaxed and verbalized
upcoming surgery. source of ten non- specific manageable level. 3.Observe Behaviours responses associated with decreased of anxiety.
-too much talking or unknown to the both medical and emotional
individual) a feeling of Long Term: 4.Notes reports of conditions.
-coo extremities apprehension caused by Identify healthy ways to insomnia. Long Term:
anticipation of danger. It is deal with and express 3.Which can point to the The patient verbalized and
-sweating an altering signal that anxiety. 5.Reviewed Coping skills in client level of anxiety. actualizes healthy ways to
warms of impending danger post. deal with and express
-expresses financial and enables the individual 4.Which may be anxiety.
concerns to take measures to deal 6.Established therapeutic behavioural indicator of use
with threat. relationship, conveying of withdrawal to deal with
-increase BP: 150/100 empathy and unconditional problems.
mmHg Source: Nurses pocket guide positive regard. Note SN
by M. Doenges needs to be aware of own 5.To determine those that
-increase RR: 21cpm feelings of anxiety or might be helpful in current
uneasiness exercising core. circumstances.