ASSESSMENT NURSING SCIENTIFIC GOALS NURSING RATIONALE EVALUATION

DIAGNOSIS RATIONALE INTERVENTIONS

SUBJECTIVE Imbalanced One reason for enteral After 8 hours of INDEPENDENT: After 8 hours of
Nutrition: Less than 1. Assess general health 1. To be able to know
CUES: feeding is dysphagia or nursing nursing
Body Requirements condition what nursing
“Dire naman ini hiya related to inability to difficulty in swallowing. interventions, the interventions to be interventions, the
ingest food secondary given.
nakakakaon hin puro Neurological damage patient will be able patient was able to:
to Tuberculous
nga pagkaon kay Meningitis as brought about by certain to: 2. Establish Rapport 2. To gain patient’s
evidenced by presence and SO’s trust
naka tubo naman disease causes dysphagia.
of Nasogastric Tube
hya ada naagi it iya Tuberculosis meningitis  To maintain 3. Observe and record 3. Monitors caloric  To maintain
client’s food intake. intake or
pagkaon” as is a life-threatening or restore or restore
insufficient quality
verbalized by S.O infectious disease which nutritional of food nutritional
Consumption.
causes the cerebral cortex status status
“Dako na ini an iya to swell. Functions of the  Demonstrate 4. Review nutritional 4. Identifies  Demonstrate
history, including deficiencies and
gin gas’an tikang cerebral cortex includes stable stable
food preferences. suggests possible
han una.” As relay of impulses to weight or interventions. weight or
verbalized by S.O cranial nerves which progressive progressive
affect the weight gain 5. Determine child’s 5. Identifies individual weight gain
current nutritional nutritional needs
glossopharyngeal (CN toward goal. toward goal.
status using age- and provides
OBJECTIVE IX) nerve which is appropriate comparative
measurements, baseline.
CUES: responsible for
including weight and
swallowing reflex body build, strength,
activity level, and
 Body weight: resulting to dysphagia.
sleep and rest cycles.
40.7 lb
6. Auscultate bowel 6. Provides
(Normal bpddy Nutrition is the most
sounds. Note information about
weight for age: basic aspect of our characteristics of digestion and bowel
stool, including color, function and may
62lbs.) body’s ability to function
amount, and affect choice and
timing of feeding..
 Appears well. Enteral feeding is
lethargic often chosen by the
 NGT tube noted physician maintain
 Muscle wasting dietary and metabolic
due to severe needs of client’s with
illness functional
 Loss of gastrointestinal tract with
subcutaneous fat inability to take enough
 Dry skin nutrition or dietary
calories orally.
Source: Medical-surgical
nursing: Reviews and
rationales by Mary Ann
Hogan
frequency of bowel
movements. .
7. Administer enteral 7. Ideal caloric intake
feeding as indicated per individual is
depending on the usually calculated
nutritional needs of to estimate the
the client metabolic needs of
the client.
8. Always place client 8. Aids in preventing
in high fowler’s aspiration.
positon. Elevate the
head of the client
while feeding.
9. Ensure patency of the 9. Some enteral
enteral tube before formulas and some
and after feeding with medications may
water clog the tube
flushing it with
water will maintain
its patency.
10.
10. Encourage or assist 11. Diminishes
with good oral bacterial
hygiene before and Growth,
after minimizing
Meals; use soft- possibility of
bristled toothbrush infection.
for gentle brushing.