1.

Imbalance nutrition: less than body requirements maybe related to condition that interfere with nutrient intake( cancer and associated treatment) as manifested by: a. Report of loss of appetite and inadequate food intake b. Weight loss (50 kg decrease to 48 kg)

Goals of care After eight hours of medical and nursing intervention patient will be able to: a. Increase in appetite b. Demonstrate behaviors to regain weight

Nursing Intervention INDEPENDENT Assessment Assess condition of skin, nails, hair, oral cavity; desire to eat. Weight daily and compare with the admission weight.

Rationale

Evaluation

Patients response

Provides the opportunity to observe deviations from normal clients baseline, and it influences the choice of intervention. Establish baseline, aids in monitoring effectiveness of therapeutic regimen, and alerts nurse in appropriate trends in weight loss. To identify factors that affect ingestion and / or digestion of nutrients.

DONE

Has good kin turgor; hair is thick and evenly distributed; tongue is in the center , no lesions noted; has loss of appetite. Admission weight of 50 kg; weight in feb. 21, 2011 is 48kg and it decrease.

DONE by the staff nurse

Determine interest in eating and availability to chew, swallow, and taste. Discuss eating habits, including food preferences, and intolerance. Therapeutic Encourage client to eat all meals.

DONE

Patient has no interest in eating, able to swallow soft foods and complain that she could not taste the food being eaten.

Client may demonstrate loss of interest in food because nausea, fatigue, generalized weakness, malaise. Reduces sensation of abdominal fullness and may enhance intake

DONE

Patient cannot consume the meal that is being served.

Provide small, frequent feedings of soft/ easily digested foods if able to swallow.

DONE

Patient is able to eat small amount of food that is given to her.

Provide mouth care before meals. Assist patient in highfowlers position for meals Health teaching Teach client significant others develop nutritionally balanced home meal plans.

Eliminating unpleasant taste may enhance appetite. Facilitate swallowing and reduce risk for aspiration. Promotes understanding of individual needs and significance of nutrition in healing and recovery process.

DONE by the folk

Patient appetite does not change.

DONE

Patient was able to eat in high fowlers position.

DONE

Patients significant others agree with the teaching and shows understanding.

Instruct significant others to provide frequent rest periods COLLABORATIVE Monitor laboratory studies; e.g. electrolyte,serum glucose, liver enzymes, CBC, total protein, transferring.

Helps conserve energy especially when metabolic requirements are increase.

DONE

Patient sleeps comfortably in her room.

Serum chemistries; blood counts, and lipid profiles are performed before initiation of therapy, providing a baseline for comparison with repeat (monitoring) studies to determine therapy needs/complications.

DONE

Patients sodium is 133mmol/L which is decrease, serum glucose of 134 mg/dL(02-2211)

Administer medication as indicated; Multivitamins preparation like Appebon with iron. Administer dextroseelectrolyte or dextrose amino acid and lipid emulsion solution as

Is given to enhance the appetite

DONE by the staff nurse DONE

Patient can not consume served meals and complain of loss appetite. Provide the patient needed nutrition. Not enough to supply patients need patient is still losing weight and weak.

Solution provide calories, essentials amino acids, and micronutrients, usually combined with lipids for complete nutrition

indicated.

known as nutrient admixtures(TNA). Solutions are modified to meet specific needs. May be required to provide nutrients when patient is unable to swallow.

Provide enteral tube feeding, TPN, lipids if indicated.

Not DONE

GENERAL EVALUATION: After 8 hours or medical and nursing intervention, patient was able to: a. Patient does not show increase in appetite b. Show some behaviors to maintain the weight. Goals were not met.

2. Disturbed thought processes maybe related to metabolic state as manifested by: a. Easy distractibility/ altered attention span b. Impaired ability to make decisions c. Altered sleep pattern Goals of Care After eight hours of medical and nursing interventions, patient will be able: a. Demonstrate behaviors to change or prevent malnutrition b. Displayed improvement ability to make decisions. Nursing Intervention INDEPENDENT Assessment Assess dietary intake / nutritional status. Assess attention span / distractibility and ability to make decisions or solve problem. Therapeutic Listen to or avoid challenging irrational. Illogical thinking. Present reality concisely and briefly. Reorient to time/place/person, as needed. Maintain a pleasant, quiet environment and approach client in a slow, calm manner. Refrain from forcing activities and communication Rationale Evaluation Patients Response

To identify causative / contributing factors To determine the ability to participate in planning/ executing care.

DONE DONE

Patient eat small amount of served food. Patient is easy distracted and can not decide on her own.

It is difficult to respond logically when thinking ability is physiologically impaired. Client needs to hear reality, but challenging client leads to distrust and frustration. Inability to maintain orientation is a sign of deterioration

DONE

Patient accept what is being said to her, but does not respond with the questions ask.

DONE

Patient is oriented to place but not in time and person. She can identify some of her folks but some are can not. Patient is able to rest in her room.

Client may respond with anxious or aggressive behaviors if startled of over stimulated. Client may be feel threatened and may withdraw or rebel.

DONE

DONE

Patient sometimes do not cooperate with the activities.

Health teaching Instruct significant others to be aware of clients distorted thinking

Allows caregiver to have more realistic expectations of client and provide appropriate information and support.

DONE

s Patients significant others is aware of patients distorted thinking.

COLLABORATIVE Review electrolyte/ renal function test Imbalances negatively affect cerebral functioning, and require correction before therapeutic intervention can begin. DONE Serum calcium and potassium are normal and decrease sodium with a result of 133 mmol/L

After eight hours of medical and nursing procedures patient was able to: a. Patient shows little interest in preventing malnutrition b. Display improvement in making decisions. Goals are partially met.