Assessment Diagnosis Planning Intervention

Subjective Data: Fatigue related to increase in After 12 hours of proper - Encourage the patient to
- As verbalized by the physical exertion as evidenced nursing interventions, the express feelings about
patient, (…… I by headaches, sleepiness, patient will verbalize increased health concerns.
CARRIED A LOT OF weakness, and sore muscles. in energy and improved of well- - Assess the patient’s
STUFF AND I being. nutritional intake of
WALKED A LOT.” calories, protein, minerals,
- “MY BODY IS VERY and vitamins
TIRED, AND MY - Assist the patient to
MUSCLES ARE SORE. develop a schedule for daily
I FELT DIZZY AND MY activity and rest.
HEAD HURTS.” - Minimize environmental
- The patient experienced stimuli especially during
headaches, weakness, rest time of the patient.
sleepiness, and sore
muscles.
Assessment
Subjective Data:
As verbalized by the patient, “I
am fat….) “I am not satisfied
with my body; I want to be
thinner”
Diagnosis Planning
Disturbed body image related to Short term goal
overweight as evidenced by the - After 1 week of proper
verbalization of the patient “I am nursing intervention, the
fat….)” “I am not satisfied with patient will able to
my body image; I want to be demonstrate a change in
thinner” eating patterns and
involvement in individual
exercise program.
Long-term goal
- After 1 month of proper
nursing interventions, the
patient will able to show
signs of weight loss.
Intervention
- Encourage the patient to talk
about health concerns, fears,
and anxieties.
- Encourage the patient to
make an exercise health
program.
- Encouraging the patient to
make a diet meal plan.
- Providing thorough teaching
and complete aftercare
instructions to the patient
- Measuring the body size of
the patient per day.
- Encouraging the patient to
see dietician and fitness
coach.
Assessment Diagnosis Planning Intervention

Subjective Data: Readiness for enhanced

- “I always drink soft nutrition related to After 4 hours of proper - Encourage the patient to do a lot
drinks” consumption of sugar- nursing interventions, the of activities and to create healthy
- “I don’t have any food sweetened beverages, lack of patient will able to integrate meal plan.
restriction” physical activities, food intake healthy meal planning and - Assess the patient’s motivation
- “I like any food” that exceeds body needs, and prepping into his or her daily for changing their eating habits.
- Rest time: 11:00 P.M lack of sleep. routine and will verbalize the - Teach the patient about the
- Exercise: None As evidenced by the benefits of adopting healthy appropriate amount of calorie
verbalization of the patient, eating habits. intake.
- “I always drink soft - Encourage the client to eat from
drinks” the different food groups and
- “I don’t have any food explain the benefits of each food
restriction” group.
- “I like any food” - Encourage to drink the
- Rest time: “11:00 P.M” recommended amount of water.
- Exercise: “None” - Encourage the patient to attend a
basic nutrition and cooking class.
- Provide the patient with resources
that they can refer to at home.