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West Visayas State University

College of Nursing
La Paz, Iloilo City

NURSING CARE PLAN

Nursing Outcome Nursing


Clustered Cues Rationale Rationale Evaluation
Diagnosis Criteria Interventions
Imbalanced Definition: Intake of
nutrition: less nutrients insufficient to
than body meet metabolic demands. The client will be Document client’s Useful in defining degree
requirements able to verbalize nutritional status on or extent of problem and
related to Malabsorption is the understanding on admission, noting appropriate choice of
inability to absorb inability of the digestive the importance of skin turgor, current interventions.
nutrients; system to absorb one or a balanced diet weight, and degree
decreased more of the major by of weight loss,
absorption; loss vitamins, minerals, and integrity of oral
of appetite; lack nutrients. Interruptions in The client will be mucosa,
of information; the complex digestive able to ability/inability to
insufficient process may occur demonstrate swallow, presence of
financial anywhere in the digestive changes in his bowel tones, history
resources system and cause diet as of nausea/vomiting
decreased absorption. manifested by or diarrhea.
proper food
Diarrhea, an abnormal selection. Ascertain client’s Helpful in identifying
increase in the frequency usual dietary specific needs and
and liquidity of the stool or The client will pattern, strengths. Consideration
in daily stool weight or demonstrate likes/dislikes. of individual preferences
volume, commonly occurs adequate weight may improve dietary
when the contents move so gain. intake.
rapidly through the
intestine and colon that Determine the Psychological factors
there is inadequate time for client’s attitude towards eating may
the GI secretions to be towards eating. affect one person’s
absorbed. appetite and also to
know the client’s eating
Malnutrition may be a habits.
consequence of the Monitor I&O and Useful in measuring
patient’s lifestyle, lack of weight periodically. effectiveness of
knowledge about adequate nutritional and fluid
nutrition and its role in support.
health maintenance, lack of
resources, or lack of Assess for allergies May affect dietary
appetite because of to food. Monitor choices and identify
coughing and mucus frequency, volume areas for problem solving
production. and consistency of to enhance, intake and
stools. utilization of nutrients.

Encourage and Helps conserve energy.


provide frequent rest
periods.

Encourage/provide Reduces bad taste left


oral care before and from sputum or
after respiratory medications used for
treatments. respiratory treatments
that can stimulate the
vomiting center.

Encourage small Maximizes nutrient


frequent meals with intake without undue
foods high in protein fatigue or energy
and carbohydrates. expenditure from eating
large meals, and reduces
gastric irritation.

Encourage SO to Creates a more normal


bring foods from social environment
home and to share during mealtime, and
meals with client helps meet personal,
unless cultural preferences.
contraindicated.

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