Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective data: Risk for imbalanced Short term Goal: Independent:  Intervention Short term
 “wala akong Nutrition: less than  After 2-3  Recognize depends on Evaluation:
gana body requirements days of contributing the  After 2-3
kumain” nursing factors in the underlying days of
intervention inability to cause of the nursing
Objective data: the patient eat, such as problem intervention
 Fatigue will be able to severe the patient
 Pale skin demonstrate dyspnea, demonstrate
 Nausea increased vomiting increased
Vital signs taken as appetite. copious appetite
follows: sputum, or
respiratory
Temp. 37.8
Long term Goal: treatments. Long term
BP: 110/80
 After 2-3 Evaluation:
PR: 110 weeks of  Encourage  Good oral  After 2-3
RR: 35 nursing patient to have hygiene have weeks of
02 Stat: 93% intervention good oral a positive nursing
the patient hygiene and effect on the intervention
will be able to dentition. appetite and the patient
maintain or taste of food. was able to
regain desired maintain
body weight  Provide small,  Enhance desired
frequent intake even weight
meals, though
including dry appetite may
foods, such as be slow to
toast or return.
crackers, and
foods that are
appealing to
client.

 Evaluate
general  Avoid other
nutritional complication
 state. which can
exacerbate
malnutrition
and delay
response to
Dependent therapy.
 Assist in
treatment of  May promote
underlying healing and
condition(s). strengthen
immune
system,
improve
appetite, and
enhance
general well-
being.
 Consult
dietitian and  To develop
nutritional dietary plan
team. individualize
d to client’s
specific needs
and
challenges.

References
Doenges, M. E. (n.d.).

Marilynn E. Doenges, M. F. (2014). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span. F.A. Davis.