Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective : Imbalanced After the 8 hours of1. 1. Assess the weight of the client. 1. Provides baseline data about the Partially met
nutrition: Less than nursing 2. client.
oo pumayat siya body requirements intervention, the
nung nagkasakit related to lack of patient or caregiver 2. Determine clients nutritional 2. To assess the usual food that she
siya verbalized by appetite as appetite will verbalize and history. eats even before pregnancy.
the grandmother as manifested by demonstrate
weight loss. selection of foods or 3. Determine the clients attitude 3. Psychological factors towards
Objective : meals that will towards eating. eating may affect one persons
achieve a cessation appetite and also to know the
Weight: 23 kg of weight loss. clients eating habits.
Height: 116 cm
BMI: 18.4 - 4. Educate the client regarding the 4. Education provide sample
Underweight importance of eating healthy foods information that the client may not
and its benefits to his body. be aware of, hence leading to the
kind of eating habits and diet she is
following.

5. Educate the client regarding the
vitamins and minerals that are
important such as vitamin C, iron,
calcium, and protein; and the
sources of these nutrients.
6. Plan with the client his desired
meals.
5. For the client to be aware of the
needed nutrients by her body to
nourish herself and her baby
throughout the pregnancy. Also,
giving sources of these nutrients
helps the client to easier familiarize
herself as to what foods she may
include in her diet.
6. Involving the client to his plan of
care gives the client the feeling of
independence. It also personalizes
the plan of care since the client
does make the choices in some

7. Suggest ways that may
assist the client in eating
a. Ensure pleasant environment.
b. Facilitate proper positioning
8. Instruct the client to avoid
caffeinated beverages.
9. Instruct the client to avoid junk
foods.
10. Instruct the client to follow the
prescribed number of servings of
the meals included in his meal
plan.
11. Encourage the client to
maintain the intake of the healthy
foods needed by his body to
achieve ideal body weight.
aspects of the plan.
7. A pleasant environment gives
the client a relaxed feeling and will
not spoil her appetite and proper
positioning reduces the risk of
aspiration and heartburn.
8. Caffeinated beverages may
decrease the appetite and will make
the client feel full easily.
9. Junk foods have empty calories
that provide no nutritional help to
the client. The weight gain that
these foods may bring is of no good
for the client and her baby.
10. Too much food intake is not
good for the body. Too much
weight gain, which is out of the
expected, may bring about
complications, such as diabetes
mellitus.
11. To provide nourishment to the
client that keeps both of them
healthy.
 Assessment Diagnosis Planning Intervention Rationale Evaluation
S> Hindi tuloy Disturbed Sleeping Long Term 1. Provide quiet environment 1. Provides a conducive Goal met;
tuloy ang tulog niya Pattern related to Outcome: (straighten sheets). environment for the client to relax. After 2 hours
kasi nagigising siya interruption for After 1 week of of nursing
pag may nag ra monitoring lab nursing 2. Provide comfort measures (back 2. Soothes and relaxes the client. interventions,
rounds na doctor o results, therapeutic, interventions, the rub). the client
nurse as verbalized and other generated client will report stated two
by the mother of the awakening, improvement in 3. Arrange care to provide 3. Promote wellness. ways to
client. quality of sleep uninterrupted sleep. improve sleep
pattern. pattern such
4. Explore other sleep aids. (warm 4. Promote wellness. as providing a
O> The client cant Short Term bath or milk) quiet
easily awakened Outcome: environment
during rounds. After 2 hours of (straightening
nursing sheets) and
interventions, the comfort
client will state two measures
ways to improve (back rub).
sleep pattern such as
providing a quiet
environment
(straightening
sheets) and comfort
measures (back
rub).