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.