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Assessment Diagnosis Planning Nursing Intervention Rationale Evaluation

1. Note real, exact 1. These

weight; do not anthropomorphic
Subjective data: Imbalanced Short term goals: estimate. assessments are The goals and
nutrition: less vital that they objectives have been
“Wala akong ganang than body After the nursing need to be partially met by the
kumain” as requirements r/t interventions during accurate. These end of the nursing
verbalized by the inadequate food the shift the patient will be used as intervention as
patient intake aeb pt. will be able to: basis for caloric evidenced by:
and nutrient
stating “Wala 1) Consume at least requirements.
Objective data: akong gana 50% of
kumain.” breakfast, lunch Short term goals:
- weight: 28 kg
and dinner trays
2. Take a nutritional 2. Family members 1) Pt. was able to eat
- pale conjunctiva at the end of the history with the may provide more more than 50% of
day participation of accurate details on
- appears weak the meals set
relatives. the pt.’s eating
for the day
- abdominal cramping habits, especially
2) Identify
if pt. has altered
- c diarrhea perception.
requirements and 2) “Dapat mas
recognize factors kumakain ako ng
leading to being gulay at prutas para
underweight 3. Note the pt.’s 3. Various factors madaming
perspective and determine the nutrisyon at dapat
feeling toward type, amount, and palagai akong
eating and food. appropriateness of kumakain sa
Long term goal: food utilized. tamang oras.” as
stated by the pt.
After 1 wk of the 4. Offer small volumes
nursing intervention of light liquids as an
appetizer before 4. Small volumes of
the patient will be liquids stimulate
meals. Long term goal:
able to: gastrointestinal
tract, which
1. Progressively 1. Pt. weights 30 kg
gains weight by the end of the
5. Assess pt.’s ability
to obtain and use 5. Several factors
essential nutrients. may affect the
pt.’s nutritional
intake, so it is
necessary to
6. Prevented assess accurately.

6. May have a
negative effect on
7. Consult appetite/eating.
team as indicated

7. To implement a
nutritional plan
for the pt.

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