DAVAO DOCTORS COLLEGE

General Malvar St., Davao City

Nursing Program

NURSING CARE PLAN

Name of Patient: Patient Z Date of Admission: January 15, 2023 Room: 401a Age: 42-year-old
Sex: F Civil Status: Married Chief Complaint: Irregular contraction coupled with lower back pain Attending Physician: Dr. Ran

DATE & TIME CUES NURSING DIAGNOSIS GOALS & OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION
January 15, Subjective: Imbalanced Nutrition related to After 8 hours of nursing INDEPENDENT INDEPENDENT After 8 hours of nursing
2023 unhealthy food choices as intervention the patient will 1. Assess client’s height, 1. Having a high BMI intervention the patient
8:00 AM “Gilihian nako run- dark evidenced by overweight body be able to demonstrate weight, and BMI. during pregnancy has was able to demonstrate
chocolates, M&M mass index. effective behavior as been linked to an effective behavior as
peanuts ug peanut manifested by: increased risk of manifested by:
butter supper crunch. various health
Dili unta itom akong Scientific Basis: A.) Client verbalizes problems for a baby. “GOAL PARTIALLY MET”
anak. Ana man gud ang accurate
tinuuhan sa mga information about 2. Obtain a thorough 2. The most appropriate A.) Client verbalized
katigulangan.” As Intake of nutrients insufficient benefits of weight history, especially family patients for the nursing the information,
verbalized by the client. to meet metabolic needs. loss. history. intervention of Weight importance, and
Imbalance Nutrition: More B.) Client fulfills Management are adults benefits in gaining
Objective: Than Body Requirements occurs desired weight loss with no major health weight loss.
when the individual’s metabolic in a reasonable problems who require B.) Client shows
Weight: 170 lbs and nutritional demands are period. diet therapy. willingness in
Height: 5 feet and 5 overly supplied. Like a machine, C.) Client will identify making change.
inches the body needs to be supplied inappropriate 3. Assess dietary intake 3. Data may not be fully C.) Client takes walk
BMI: 28.3 (Overweight) with the right kind and the right behavior and through 24-hour recall or accurate. Permits sometime and do
- Patient has a amount of fuel. Nutrients we consequences questions regarding usual appraisal of patient’s moderate exercise
family history ingest through food should be in associated with intake of food groups. knowledge about diet that is fit for her.
of Type 2 adequate amounts to essentially overweight or also. D.) Client knows what
diabetes meet our body’s metabolic weight gain. the foods are she
mellitus. demands. D.) Client organizes 4. Encourage exercise. 4. Metabolism and should eat now
relevant activities utilization of nutrients and has a control
requiring energy are improved by in her eating
expenditure into activity. habits.
daily life. 5. Educate patient about 5. Permanent lifestyle
E.) Client demonstrates adequate nutritional changes must occur for
appropriate intake. A total plan weight loss to be long
selection of meals permits occasional treats. lasting. Excluding all
or menu planning treats is not
toward the goal of sustainable. During
weight reduction energy restriction, a
patient should
consume 72 to 80 g of
high biological value
protein per day to
lessen risk of
ventricular
arrhythmias.

6. Teach stress reduction 6. The patient needs to

methods as alternatives substitute healthy for
to eating. unhealthy behaviors.

7. Advice client to eat 7. To have a healthy body

nutritional food such as and skin. The nutrients
green-leafy vegetables. will also pass to the
baby.

DEPENDENT DEPENDENT
1. Prescribed medication as 1. This is advised to fill
ordered. nutritional gaps and
prevent
developmental
abnormalities at
birth like spina bifida.

2. Maintain Iv fluid 2. To prevent or treat

dehydration

COLLABORATIVE COLLABORATIVE
1. Refer to a dietitian for a 1. Dieticians assist with
complete nutrition goal setting,
assessment and methods understanding food
for nutritional support. labels, meal and recipe
planning, portion
control, and making
better food choices.
 ANGELICA CONTRERAS, SN

References

Plemper, rebecca. (2022, March 19). Imbalanced nutrition: More than body requirements – nursing diagnosis & care plan. Nurseslabs. Retrieved February 14, 2023, from
https://nurseslabs.com/imbalanced-nutrition-more-body-requirements/

Wayne, G. B. (2022, May 8). Imbalanced Nutrition: Less Than Body Requirements Nursing Care Plan. Nurseslabs. Retrieved October 8, 2022, from
https://nurseslabs.com/imbalanced-nutritionless-bodyrequirements/

Vera, M.(2022). 4 Obesity nursing care plans. Nurseslabs. Retrieve from https://nurseslabs.com/4-obesity-nursing-care-plans/