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Saturday, November 27, 2010

NCP- Imbalance Nutrition (Click Here)


ASSESSMENT
NURSING DIAGNOSIS
OBJECTIVE
INTERVENTION
RATIONALE
EVALUATION

Subjective:
“wala akong gana kumain pag minsan din na rin ako makakain kasi sinusuka ko din at minsan din pinagbabawalan ako kumain ng doctor dahil sa aking kalagayan”
As verbalized by the client.

Objective:
-restless

-loss of appetite

-nausea and vomiting

-muscle weakness

-bipedal edema (with foot necrosis)
Imbalance nutrition less than body requirements related to inability to ingest food as evidenced by nausea and vomiting.
Goal:
The client will have a adequate nutritional intake

Short-term
After 2 hours of nursing intervention the client will be able to verbalize understanding of causative factors when known and necessary interventions

Verbalized that that the feeling of nausea and vomiting is lessened

Long-term:
After 1 week of nursing intervention the client will be able to:

Demonstrate lifestyle changes to regain and maintain appropriate weight


Demonstrate a progressive weight gain toward goal

Demonstrate that the feeling of nausea and vomiting is lessened.



Independent:
Assess the client dietary status


Assess for factors contributing to altered nutritional intake
(nausea and vomiting, depression)


Provide patient food preferences within dietary restrictions


Promote intake of low protein foods, low salt, low fat high fiber meals.
(e.g. 1 cup of rice, 2 banana per meal)

Limit the fluid intake


Instruct to avoid food that increases gastric motility
(e.g. hot, cold, spicy, caffeinated beverages)


Promote a pleasant relaxing environment including socialization when possible

Dependent:
Administer medications as indicated

Provide and implement dietary modifications

Collaborative:
Consult a dietitian as indicated

Discuss the rationale of dietary restriction in relation to kidney disease

Provide a data about dietary status

Information about other factors that may be altered to promote adequate dietary intake is provided

Increased dietary intake is encouraged


Reduces source of restricted food and providing proteins for growth and healing





Avoid the increase of   gastric motility

























Promote pt. understanding about his condition.
Goal: partially met as manifested by the client ability to:

verbalize understanding of causative factors when known and necessary interventions

Verbalized that that the   feeling of nausea and vomiting is lessened


Demonstrate that the feeling of nausea and vomiting is lessened.



ASSESSMENT
NURSING DIAGNOSIS
OBJECTIVE
INTERVENTION
RATIONALE
EVALUATION

Subjective:
“madalas nahihirapan ako   huminga at parang sumisikip yung dibdib ko” as verbalized by the client.

Objective:
-restless

-dyspneic

-pale skin color

-difficulty in breathing

-difficulty in vocalizing

-nasal flaring noted

-crackles heard upon auscultation

-RR= 27




Ineffective airway clearance related to accumulation of fluid in the lungs secondary to pneumonia as evidenced by ( rapid respirations, nasal flaring, and adventitious breath sounds)
Goal:
The client will improved the airway patency

Short term:
After 4 hours of nursing intervention the client will be able to verbalized that the DOB experienced is lessened or relieved

Long term:
After 1 week of nursing intervention the client will be able to:

Demonstrate behavior and techniques to maintain a clear and patent airway.

Verbalized understanding   about the cause and management regimen

Independent:
Monitor rhythm, rate, depth   and effort of respiration

Auscultate breath sounds noting for any adventitious or abnormal breath sounds

Elevate HOB every two hours


Position client appropriately.
(sitting position with head slightly flexed, shoulders relaxed and knees flexed)


Encourage deep breathing and   controlled coughing exercises










Dependent:
Institute respiratory treatments (e.g.  O2 therapy, nebulizer etc.)


Administer prescribed medications as indicated


Collaborative:

Consult a respiratory therapist

Diagnostic test such as (chest x-ray, ABG etc.)


Provide a basis for adequacy of ventilation

To identify if there are any presence of adventitious breath sounds


Enhancing ventilation to both lung segments

Lying flat can cause abdominal organs to shift toward the chest, crowding the lungs making it more difficult to breath)

Deep breathing promotes   oxygenation while controlled coughing accomplished the closure of the glottis and the explosive expulsion of air in the lungs by the work of abdominal and chest muscles


A variety of respiratory treatments may be used to open constricted airways


Goal met as the client verbalized and manifest condition:

-improved and maintain a patent airway

-verbalized that the DOB experienced is lessen or relieved

-demonstrate techniques and behavior to maintain a open clear airway

-verbalized understanding about cause and management regimen.

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