Imbalanced nutrition: Less than body requirements

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective: Reported inadequate food intake, altered taste sensation, loss of interest in food Decreased subcutaneous fat or muscle mass 10% to 20% below ideal body weight or weight below normal for age, height, and build ( V/S taken as follows: T= 36.6 C RR= 18 bpm PR= 80 bpm BP= 110/90 mmHg

Imbalanced nutrition: Less than body requirements related to loss of appetite.

After 3 hours of nursing interventions, the patient will be able to demonstrate behaviors, lifestyle changes to regain and/or maintain appropriate weight

INDEPENDENT: >Monitor daily food intake; have patient keep food diary as indicated. >Assess weight; measure or calculate body fat and muscle mass via triceps skinfold and midarm muscle circumference or other anthropometric measurements >Assess skin/mucous membranes for pallor, delayed wound healing, enlarged parotid glands.

>Identifies nutritional strengths/deficie ncies.

>To establish a baseline prarameters

Goal partially met. After 3 hours of nursing interventions, the patient was be able to demonstrated behaviors, lifestyle changes to regain and/or maintain appropriate weight

>Helps in identification of protein-calorie malnutrition, especially when weight and anthropometric measurements are less than normal.

>Give small, frequent feedings; include patient likes or dislikes in meal preparation as much as possible, and incorporate home foods, as fitting. >Control environmental factors (e.g., strong/noxious odors or noise). Avoid overly sweet, fatty, or spicy foods. >Encourage use of relaxation techniques, visualization, guided imagery, and moderate exercise before meals.

>May improve patients craving for food and quantity of intake.

>As this may trigger nausea/vomiting response.

>May prevent onset or reduce severity of nausea, decrease anorexi a, and enable patient to increase oral intake. >Nausea/vomitin g are frequently the most

DEPENDENT: >Administer antiemetic on a regular schedule

before/during and after administration of antineoplastic agent as indicated.

disabling and psychologically stressful side effects of chemotherapy.

COLLABORATIVE: >Refer to dietitian/nutritiona l support team.

>Provides for specific dietary plan to meet individual needs and reduce problems associated with protein/calorie malnutrition and micronutrient deficiencies.

Acute pain related to inflammatory process

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Sumasakit ang likod ko as verbalized by patient. Objective: >Facial mask of pain. >Self narrowed focus. >Fatigue. V/S taken as follows: T= 36.6 C RR= 18 bpm PR= 80 bpm BP= 110/90 mmHg

Acute pain related to inflammatory process

After 3 hours of nursing interventions, the patient will be able to incorporate relaxation skills and diversional activities into pain control program

INDEPENDENT: >Investigate report of pain, noting characteristics, location, intensity (010 scale). >Provide firm mattress and small pillows.

>Helpful in determining pain management needs and effectiveness of the program. >Soft or sagging mattress and large pillows inhibits the proper body alignment. >In acute phase, total bed rest may be necessary to limit pain. >Prevents general fatigue and joint stiffness. >Heat promotes muscle relaxation and mobility, decreases pain and relieves morning stiffness. >Promotes relaxation and reduces muscle

>Suggest patient assume position of proper comfort while in bed or chair. Promote bed rest as indicated. >Encourage frequent changes of position. >Apply warm or moist compression the affected area several times a day.

Goal partially met. After 3 hours of nursing interventions, the patient was be able to incorporated relaxation skills and diversional activities into pain control program

>Provide gentle massage

tension >Encourage use of stress management techniques >Promotes relaxation, provides sense of control and may enhance coping activities

COLLABORATIVE: >Administer nonsteroidal antiinflammatory drugs as prescribed. >These drugs control mild to moderate pain and inflammation by inhibition of Prostaglandin synthesis. >To prevent further infection

>Administer antibiotic as prescribed.

Disturbed body image related to trauma/injury to spinal cord

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective: V/S taken as follows: T= 36.6 C RR= 18 bpm PR= 80 bpm BP= 110/90 mmHg

Disturbed body image related to trauma/injury to spinal cord

After 5 days of nursing interventions, the patient will be able to verbalize acceptance of self situation

INDEPENDENT: >Acknowledge and accept expression of feelings of frustration, grief, hostility. Note withdrawn behavior and use of denial.

Acceptance of this feeling as a normal response to what has occurred facilitates resolution. It is not helpful of possible to push patient ready to deal with situation. Denial maybe prolonged and be an adaptive mechanism because patient is not ready to cope with personal problems. > Enhance trust and rapport between patient and nurse.

Goal partially met. After 5 days of nursing interventions, the patient was be able to verbalized acceptance of self situation

>Be realistic and positive during treatments in health teaching and setting goals within limitations. >Provide hope within parameters of individual situation, do not give false

> Promotes positive attitude and provides opportunity

reassurance.

to set goals and plan for future based on reality. > Words of encouragemen t can support development of positive coping behaviors. >Maintain open lines of communication and provides on ongoing support for patient and family. > Promotes ventilation of feelings and allow for more helpful responses to patient. > Prepares patient for reactions of others and anticipates ways to deal with them.

> Give positive reinforcement of progress and encourage endeavors toward attainment of rehabilitation goals. > Encourage family interaction with each other and with rehabilitation team.

>Provide support group for So. Give information about how so can be helpful to patient.

>Role play social situation of concern to patient.