Foundation University
COLLEGE OF NURSING
Dumaguete City
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: At the end of my 2 days Independent: At the end of my 8
nursing care, the patient - Helps assess the hours nursing care, the
- “Wala kaayo siyay Imbalanced nutrition will be able to - Monitor and record patient’s response to patient showed the
gana mo kaon ug mo less than body demonstrate improved vital signs as needed. interventions and detect following outcomes
inom ug tubig, iya rasad requirements related to nutritional intake as - Encourage small, signs of worsening related to improving
isuka”, as verbalized by inadequate oral intake evidenced by: frequent meals instead condition nutritional intake:
the SO. due to vomiting of large portions. - Helps prevent nausea
- Stable vital signs and - Encourage the SO to and promotes better → Goal achieved
Objective: adequate energy levels. offer the patient digestion.
V/S: preferred, easily - Familiar and well- - Vital signs within
T: 36.9°C - Increased oral fluid digestible foods. tolerated foods can help normal range:
PR: 125 bpm and food consumption. -Encourage the intake of stimulate appetite and T: 36.9 °C
O2 Sat: 98% high-calorie, nutrient- prevent further PR: 108 bpm
RR: 26 cpm - Verbalize an improved dense fluids (e.g., oral vomiting. RR: 23 cpm
appetite and willingness rehydration solution, - Helps meet caloric and O2 saturation: 98%
- Multiple episodes of to eat small, frequent broth, fruit juices if fluid needs without - Verbalized improved
vomiting of previously meals. tolerated). overwhelming the appetite and willingness
ingested food - Assess for signs of stomach. to eat small, frequent
- Inability to tolerate - Show no further malnutrition such as - Early detection allows meals.
oral hydration episodes of vomiting, weight loss, muscle for timely intervention - Showed no further
- Decreased oral intake allowing for better wasting, and fatigue. to prevent episodes of vomiting,
nutrient absorption. - Position the patient in complications. allowing for better
Oral Intake: 450 mL a comfortable, upright - Helps prevent nausea nutrient absorption.
IV Intake: 376 mL position during and after and aids in digestion.
(Subtotal: 776 mL) meals. - Encourages → Partially achieved
- Educate the SO and compliance and long-
patient about the term dietary - Oral fluid
importance of proper improvements. consumption is still low.
nutrition and hydration
in recovery.
Dependent:
- Medication contributes
- Administer prescribed to overall well-being.
medications (ORS to
replace GI losses - IV fluids help maintain
vol/vol, Zinc Sulfate hydration, especially
Syrup 2.5 mL OD, at when oral intake is
bedside). compromised.
- Monitor IVF of PLR - Identifies possible
500cc running at 47cc/hr electrolyte imbalances
via soluset and monitor that need correction.
IV site condition.
- Monitor laboratory
results if available
(electrolytes, urinalysis).
