ASSESSMENT SUBJECTIVE: Wala siyang ganang kumain eh, as verbalized by the clients mother.

OBJECTIVE: Severely dehydrated Cold clammy skin Pale fatigue

NSG. DIAGNOSIS

S. EXPLANATION Severe dehydration Inability/difficulty ingesting food in appetite intake of nutrients Weight loss Imbalanced Nutrition: less than body requirements

PLANNING DISCHARGE OUTCOME: Upon discharge, the client will be able to: Demonstrate progressive weight gain towards goal Demonstrate behaviors/lifestyle changes to regain/maintain appropriate weight SHORT-TERM OUTCOME: After 8 hours of Nursing Intervention, the client/mother will be able to: Demonstrate improvement in appearance and weight Verbalize understanding of causative factors and necessary interventions

NSG. INTERVENTION INDEPENDENT: Identify client at risk for malnutrition Determine clients ability to chew, swallow, and taste food Assess weight and anthropometric measurements Note age body build, strength, activity/rest level Evaluate total daily food intake Promote adequate/timely fluid intake Promote weighing at regular intervals and document results COLLABORATIVE: Consult dieticians/nutritiona l team as indicated

RATIONALE

EVALUATION

Imbalanced Nutrition: less than body requirement related to inability to ingest food as evidenced by severe dehydration

to assess causative/contributing factors all factors can affect ingestion/digestion of nutrients to establish baseline parameters help determine nutritional needs revel possible cause of nutrition/changes in clients intake to reduce possibility of early satiety to monitor effectiveness of dietary plan to implement interdisciplinary team managements (Doenges Ed.11, p. 478-483)

PARTIALLY ACHIEVED After Nursing Intervention, the client/mother was able to demonstrate improvement in appearance and weight and verbalized understanding of causative factors and necessary interventions.