Assessment
|
Nursing DX/Clinical Problem
|
Client Goals/Desired Outcomes/Objectives
|
Nursing Interventions/Actions/Orders
and Rationale
|
*I
|
Evaluation
|
Subjective
“I do not like the food here”
“I cannot eat the stuff they give it.
It’s terrible”
Objective
Decreased input
Ate only about 25% of breakfast
tray.
Pt complains of nausea
|
Problem
Imbalance nutrition: less than body requirements
|
Long Term:
Client will identify nutritional requirements and recognize
factors leading to being underweight by the time of discharge.
|
- Provide companionship while eating to encourage eating because
patients will often eat more if other people are present at meal time (Ackley &
Ladwig, 2008, p 577).
|
|
Goal still in progress. Patient
seemed more willing to eat with student nurse present in the room, however complained
of pain and not willing to eat due to pain.
|
Continue to accompany patient
during meal times. Administer pain
medication before meals if possible to decrease amount of pain.
|
R/T
nausea, vomiting
|
Short Term:
Client will consume at least 50% of breakfast, lunch and
dinner trays at the end of the day.
|
- Monitor food intake and record any food intake less than
50% because might need to discuss with dietitian (Ackley & Ladwig, 2008, p576).
- Administer antiemetic medicine prn to decrease nausea when
eating and with medication intake so that the patient is more willing to eat (Ackley
& Ladwig, 2008, p 563).
|
|
- Goal not
met- Patient did not eat more than 50% of breakfast and lunch trays.
- Goal met. Administered antiemetic with pain medication
during breakfast.
|
- Will get order to have dietitian to come
in and evaluate to determine other foods choices for patient.
- Continue
to administer antiemetic as needed for c/o nausea.
|