Assessment Diagnosis Planning Intervention Evaluation

Subjective: Imbalance After 8 hours of Independent: After 8 hours of

nutrition: Less nursing nursing
Patient may than body intervention: -Document intervention the
report: requirements -the pt. will patient’s pt. was able to:
related to able to regain nutritional status
-Loss of frequent and or maintain on admission, -maintain
appetite cough/sputum appropriate noting skin appropriate
-Indigestion production weight. turgor, current weight
-Weight loss weight and - regain weight
degree of weight
Objective: loss, integrity of
-Poor skin oral mucosa,
turgor, dry/flaky ability/inability to
skin swallow,
-Muscle presence of
bowel tones,
wasting/loss of history of
subcutaneous nausea/vomiting
fat or
diarrhea.
-Ascertain
patient’s usual
dietary pattern,
likes/dislikes

-Monitor I&O
and weight
periodically

-observed for
anorexia and
nausea/vomiting,
and note
possible
correlation to
medications.
Monitor
frequency,
volume,
consistency of
stools
-Encourage and
provide for
frequent rest
Periods
-Encourage small,
frequent meals
with foods high in
protein and
carbohydrate

Collaborative:
-Refer to dietitian
for adjustments in
dietary
composition
-Consult with
respiratory
therapy to
schedule
treatments
1–2 hr
before/after
meals