Dainty Garcia

Rm. 404: Nasopharyngeal CA. S/P Chemo

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Imbalance Nutrition: Short Term Goal: Independent: -After 6 hours of
less than body nursing intervention,
“nanghihina ang requirements related -After 6 hours of Document actual Patients may be patient was able to
katawan ko at mejo to consequences of nursing interventions weight, do not unaware of their verbalize
walang ganang chemotherapy as client will verbalize estimate. actual weight or understanding and
kumain at hindi ko evidenced by understanding of weight loss due to demonstrate
din naman reported altered causative factors and estimating weight. selection of meals
malasahan” taste sensation. necessary that help in achieving
interventions to Obtain nutritional Patient's perception cassation of weight
promote optimum history; include of actual intake may loss and maintain or
Objective: nutrition. family, significant differ. improves ideal body
others, or caregiver weight.
-Poor muscle tone in assessment.
-Limited ROM Long Term Goal: -After 1-2 days
-Easy fatigability Monitor or explore Many psychological, patient practice and
-After 1-2 days of attitudes toward psychosocial, and demonstrate
Ht: nursing eating and food. cultural factors behavior and lifestyle
5’8 interventions, client determine the type, changes that helps in
Wt: will be able to amount, and improvement of
118lbs demonstrate appropriateness of appropriate nutrition
BMI: behaviors, lifestyle food consumed. intake.
17.94 = underweight changes to maintain
or improve Monitor Fewer families today
Vital signs: appropriate nutrition environment in have a general meal
BP: 130/80 intake. which eating occurs. together.
Temp: 36.2
PR: 99 Encourage patient Determination of
RR: 20 participation in type, amount, and
recording food intake pattern of food or
using a daily log. fluid intake as
facilitated by
accurate
documentation by
Dainty Garcia
Rm. 404: Nasopharyngeal CA. S/P Chemo

patient or caregiver
as the intake occurs.

Weigh patient To monitor

weekly. improvement in
patient’s weight.

Collaborative:

Consult dietitian for Dietitians have a

further assessment greater
and understanding of the
recommendations nutritional value of
regarding food foods and may be
preferences and helpful in assessing
nutritional support. specific ethnic or
cultural foods.

Top 3 Problem prioritization

1. Altered Nutrition: Less than body requirements
2. Fatigue
3. Risk for Altered Family Process