COLLEGE OF NURSING
NAME: ______________________________________
CLINICAL INSTRUCTOR: ________________________________
ASSESSMENT
Subjective Data:  Imbalance Nutrition
“Nanghihina ako at
nahihirapan ako kumain
dahil naisusuka ko lang ang
mga kinain ko na pagkain.
Dahil sa pagsusuka
nawalan ako ng gana na
kumain. Kaya natutulog na
lang ako .”as verbalized by
the patient.
Objective Data:
 Dry skin and
mucous membrane
 Paleness
 Poor skin turgor
 Dry lips
 leathargy
 Temp: 37.8 ° C
 BP: 122/80 mmHg
 PR: 93 bpm
 RR: 20 rpm
 Platelet count : 37 x
10^9/L
DATE: ________________________
SCORE: _______________________
DIAGNOSIS ANALYSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
 Imbalance nutrition
: Less than body can be of many Short term goal: Independent:
requirement types, some are  After 8 hours of the  Encourage the  To replace the Short term goal:
related to nausea , deficiency in nursing patient to drink deficit metabolic The goals are met after
vomiting and no protein or intervention the fluid and fluids and a few days of treatment
appetite as carbohydrates. patient will be able electrolytes. electrolytes in the because there are no
evidenced by the Dehydration is also to increase the food body. presence of imbalance
dehydration a kind of and fluid intake.  Encourage the  To prevent the nutrition, no
malnutrition, where patient to eat small patient from dehydration, emesis
the body suffers but frequent meals. sudden stomach and any symptoms. The
from low metabolic filling and prevent patient is also at the
water that vomiting, right range of weight
circulates the
system Dependent:
 Prepare a diet plan  To promote a
for the patient. complete and
balance diet that
Long term goal: will correct the
imbalance nutrition
 After 4-7 days of  Administer vitamins  To supplement the
nursing supplementation as missing vitamins
intervention the prescribed by the and minerals in the
patient will be able doctor. body
to increase the  Administer anti-  To prevent any
weight within emetic medication further lost of
normal range as prescribed by the electrolytes
according to age physician.  To rapidly replace
and show negative  Administer IV metabolic fluids and
signs of theraphy. electro
dehydration.
COLLEGE OF NURSING