Beruflich Dokumente
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Name of Student:_Judaperl D. Cabanag _________________ Clients Initials:__A.C______________________________________ Age: 37 y/o Gender: Male Civil Status:Single Religion:R. Catholic Allergies: _no known allergies to food and drugs_____________ Diet:_NPO________________________________________________ Date of Admission:_January 7, 2014; 4:15pm ____________ Diagnosis/Impression:Acute Appendicitis, Uncomplicated _
Clinical Instructor: _Mr. Julius C. Dao, RN_________ Stressor Classification: (Please check) ____ Physiological (body structure and functions) ______ Psychological (mental processes and emotion) ______ Socio-cultural (relationships, expectations) ______ Spiritual (influence of spiritual beliefs) ______ Developmental (developmental processes over the lifespan)
NURSING DIAGNOSIS
Assessment Subjective: Magsige man gud ug sakit akong tiyan mao ng di ko ganahan mukaon 9 days na, as verbalized by patient Objective: received conscious and coherent restlessness noted reported weight loss of 2 kg in one week reported to have decrease in appetite Diagnosis Imbalanced Nutrition: Less than Body Requirements related to decreased appetite secondary to constant abdominal pain
NURSING GOALS
Mutual Planning
(Goal attainable within the shift)
NURSING OUTCOME
Interventions
(with Rationale & Source)
Actual Evaluation
After eight hours of nursing interventions, patient will be able to: verbalize understanding of appropriate food intake and diet restrictions; take in an increase quantity of foods with necessary nutrients with gradual diet progression
Theoretical basis: on NPO status for 2 days with sthenic body built reported to have abdominal pain which ranges from mild to moderate pain with normoactive bowel sounds dryness of oral mucosa noted pain score: 2 out of 10 Adequate nutrition is necessary to meet the bodys demands especially when having diseases since this can help in providing the body with the essential nutrients and minerals to aid in recovery. Nutrition on can be affected by disease states which could involve discomfort in taking in food as well as diet restrictions. During times of illness, adequate nutrition plays an important role in maintenance of the wellbeing of the patient; however, appetite may decrease illness states. - Smeltzer and Bare, 2010
Preventive:
I: Encourage to eat small but frequent feedings. R: Promote adequate intake of nutrients with decreased energy levels to prevent early satiety. S: Gulanick/Myers, 2007 I: Provide assistance and encouragement to eat more as needed during mealtime. R: Patient may need help with eating. S: Kemper, 2005
Bibliography:
_______Gulanick, M & Myers, J. (2007). Nursing Care Plans. 6th ed. Elsevier (Singapore). Pte. Ltd.____________________________________________ ________Kemper, D. (2005). Healthwise Handbook. Healthwise, Incorporated, Boise Idaho.__________________________________________________ ________ Smeltzer, et. Al (2010). Brunner & Suddharths Textbook of Medical-Surgical Nursing. 12th ed. Wolters Kluwer Health Lippincott Williams & Wilkins._