Cues/Needs Nursing Scientific Goals and Nursing Intervention Rationale Evaluation

Diagnosis Explanation Objectives

Subjective Imbalanced TBI has a dynamic SHORT TERM INDEPENDENT SHORT TERM
“Sobra ang pinayat nutrition less pathophysiology After 16 hours of  Determine the To identify all factors After 16 hours of
niya kumpara nung than body that evolves in nursing client’s ability to that affect ingestion nursing intervention,
hindi pa nang yare requirements r/t time, consisting of intervention the chew, swallow, and digestion of the goal was met as
itong brain injury metabolic patient will: and taste food. nutrients. evidenced by:
primary injury,
niya” as verbalized changes, fluid  Display Evaluate teeth and  The patient
followed by a
by the significant restriction, and normalization gums for poor displayed
others inadequate combination of of laboratory oral health. normalization of
intake systemic disorders values and be laboratory values
(hypoxia, free of signs of  Assess weight, To identify and be free of signs
hypotension, and malnutrition measure muscle deviations from then of malnutrition
Objective hypercarbia) and  The significant mass, or calculate norm and to establish  The patient or the
 Weight local events, which other or patient body fat by means baselines parameters significant other
loss from together lead to will verbalize of anthropometric verbalized
80kg to 64 secondary injury understanding measurements and understanding of
kg (Rosenfeld et al., of causative growth scales. causative factors
 Fatigue 2012). As brain is factors when when known and
 Pale dry known and  Give the patient To lessen possibility necessary
the functional
skin necessary small, frequent of nausea, vomiting interventions
regulator for and diarrhea.
 Brittle hair interventions feedings
metabolic activities, LONG TERM LONG TERM
Laboratory values
a complex milieu of After 3 weeks of  Start nasogastric Naso gastric tube After 3 weeks of
 Serum
albumin
metabolic nursing feeding as soon as allow the stomach to nursing intervention,
2.8 g/dl alterations may intervention the condition be decompressed the goal was met as
 Potassium occur in TBI, patient will: stabilizes unless which can aid evidenced by:
6.2 mmol/L consisting of  Demonstrate there is discharge mechanical  The patient
hormonal changes, progressive of CSF from the ventilation, reduce demonstrated
 Chloride
aberrant cellular weight gain nose the risk of aspiration progressive weight
70 mmol/L
from 64kg to and especially gain from 64kg to
 Sodium metabolism, and
70kg provide a route for 71 kg
100 mEq/L inflammatory
 Demonstrate nutritional feeding.  The patient
 RBC male cascade(Cook,
3.9 behaviors, demonstrated
2008). The
cells/mcL lifestyle DEPENDENT behaviors, lifestyle
abnormal metabolic To identify abnormal
 WBC changes to  Monitor laboratory changes to regain
processes, mainly regain and data like serum, laboratory findings and maintain
 3,500 including and focus that in
maintain albumin, appropriate weight
cells/mcL hypermetabolism, intervening the
appropriate transferrin, amino
Vital signs hypercatabolism, problem.
weight acid, iron, BUN,
HR:120 bpm
and glucose nitrogen balance
BP 140/90
intolerance, have studies, glucose,
been recognized as liver, function,
incredibly essential electrolytes, total
elements of lymphocyte count. In order to set
COLLABORATIVE nutritional goals
secondary injuries
 Collaborate with when client has
interdisciplinary specific dietary
Reference: Wang, team (nutritionist needs, malnutrition is
X., Dong, Y., Han, or dietrician) profound, or long-
X., Qi, X. Q., term feeding problem
Huang, C. G., & exist.
Hou, L. J. (2013).
Nutritional
support for Nutritional support
patients  Consider the may be recommended
sustaining possible need for for patients who are
parenteral unable to maintain
traumatic brain
nutritional support nutritional intake by
injury: a the oral route
with the patient,
systematic review
family, and nurse,
and meta- as appropriate.
analysis of
prospective
studies. PloS
one, 8(3),
e58838.
https://doi.org/10.
1371/journal.pone
.0058838