ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Altered Nutrition: Less After 1-2 hours of nursing Monitor daily food intake; Identifies nutritional After 1-2 hours of nursing
“Hindi ako makakain Than Body Requirements intervention Participate in have patient keep food strengths and intervention
ng maayos at related to Hypermetabolic specific interventions to diary as indicated. deficiencies. Patient demonstrate
nanghihina ako” state associated with stimulate increase in appetite and
cancer appetite/increase dietary Measure height, weight, If these measurements interest in treatment
Objective: intake. and tricep skinfold fall below minimum regimen
s/p chemotherapy thickness (or other standards, patient’s chief
s/p mastectomy anthropometric source of stored energy
weak looking measurements as (fat tissue) is depleted.
appropriate). Ascertain
vital signs amount of recent weight
BP 120/80 loss. Weigh daily or as
BT 36.8 indicated.
PR 84
RR 18 Assess skin and mucous Helps in identification of
membranes for pallor, protein-calorie
delayed wound healing, malnutrition, especially
enlarged parotid glands. when weight and
anthropometric
measurements are less
than normal.

Encourage patient to eat Metabolic tissue needs

high-calorie, nutrient-rich
diet, with adequate fluid
intake. Encourage use of
supplements and
frequent or smaller meals
spaced throughout the
day.
are increased as well as
fluids (to eliminate waste
products). Supplements
can play an important
role in maintaining
adequate caloric and
protein intake.
Create pleasant dining Makes mealtime more
atmosphere; encourage enjoyable, which may
patient to share meals enhance intake.
with family and friends.

Encourage open Often a source of

communication regarding emotional distress,
anorexia. especially for SO who
wants to feed patient
frequently. When patient
refuses, SO may feel
rejected or frustrated.

Adjust diet before and The effectiveness of diet

immediately after
treatment (clear, cool
liquids, light or bland
foods, candied ginger,
dry crackers, toast,
carbonated drinks). Give
liquids 1 hr before or 1 hr
after meals.
adjustment is very
individualized in relief of
post therapy nausea.
Patients must experiment
to find best solution or
combination. Avoiding
fluids during meals
minimizes becoming “full”
too quickly.

Control environmental Can trigger nausea and

factors (strong or noxious vomiting response.
odors or noise). Avoid
overly sweet, fatty, or
spicy foods.

Encourage use of May prevent onset or

relaxation techniques, reduce severity of
visualization, guided nausea, decrease
imagery, moderate anorexia, and enable
exercise before meals. patient to increase oral
intake.

Identify the patient who Psychogenic nausea and

experiences anticipatory vomiting occurring before
nausea and vomiting and chemotherapy generally
take appropriate does not respond to
measures. antiemetic drugs.
Change of treatment
environment or patient
routine on treatment day
may be effective.