Assessment Diagnosis Planning Interventions Rationale Evaluation

SUBJECTIVE: Imbalanced At the end of the shift Independent Goals MET

> Mother reported of Nutrition less the client will be able • Restrict solid To allow for bowel
patient’s change of than body to have a good food intake, as rest/reduced intestinal At the end of
appetite and requirements appetite as manifested indicated workload the shift the
frequent vomiting of related to lack by showing increased client was
the client of appetite, interest in eating or able to have
vomiting and drinking his milk • Provide for To avoid foods/ a good
stomach pain formula. changes in substances that appetite as
dietary intake precipitate diarrhea manifested
OBJECTIVE: by showing
 Unwillingness increased
to eat/ feed • Assess for Indicating hydration interest in
or drink his presence of eating or
milk formula postural drinking his
 Changed hypotension, milk formula.
diaper 3x tachycardia,
with loose skin
and hydration/turgo
deformed r, condition of
stools mucous
 Vomited 2x membranes
after feeding
 Abdominal • Weigh infant’s To determine amount of
distention diapers output and fluid
noted upon replacement needs
palpation
 Upon • Encourage oral
auscultation, intake of fluids
hyperactive containing
bowel sounds electrolytes,
noted. such as juices,
 Irritated and bouillon, or
crying. commercial
preparation as
 appropriate.

• Assist, as Because skin breakdown

needed, with can occur quickly when
pericare after diarrhea is present.
each bowel
movement.

• Provide prompt To keep the area dry

diaper change because moisture can
and gentle adhere skin breakdown
cleansing

• Apply
lotion/ointment
or petroleum
jelly as skin
barrier, as
needed.

• Provide dry
linen, as
necessary.

• Expose
perineum/
buttocks to air;
use heat lamp
with caution, if
needed.

• Increase oral
fluid intake and
return to
 normal diet, as
tolerated.

• Encourage
nonirritating
liquids.

• Discuss Diarrhea maybe result of

possible aggravated by
change in intolerance to specific
infant formula. formula.

• Review food
preparation, To prevent diarrhea from
emphasizing recurring
adequate
cooking time
and proper
refrigeration/st
orage.

• Emphasize the
importance of To prevent bacterial
hand washing. growth/ contamination

• Document Patients may be

actual weight; unaware of their actual
do not weight or weight loss
estimate. due to estimating weight.

• Obtain Mother’s perception of

nutritional actual intake may differ.
history; include
 family,
significant
others, or
caregiver in
assessment.

• Determine
etiological
Proper assessment
factors for
guides intervention.
reduced
nutritional
intake.

• Monitor or
explore child’s Many psychological,
attitude or psychosocial, and
response cultural factors
toward eating determine the type,
and food. amount, and
appropriateness of food
consumed.

• Monitor Fewer families today

environment in have a general meal
which eating together. Evaluates the
occurs. family eating practices
and determines how it
affects the child’s
nutrition.
• Encourage the Determination of type,
mother in amount, and pattern of
recording food food or fluid intake is
intake using a facilitated by accurate
daily log. documentation by the
mother as the intake
occurs; memory is
insufficient.

During aggressive
• Weigh patient nutritional support,
weekly. patient can gain up to
0.5 pound/day.

Depending on the
etiological factors of the
• Establish problem, improvement in
appropriate nutritional status may
short- and take a long time. Without
long-range realistic short-term goals
goals. to provide tangible
rewards, patients may
lose interest in
addressing this problem.

Ensure a pleasant
• Suggest to the environment, facilitate
 mother some proper position, and
ways to assist provide good oral
patient with hygiene and dentition.
meals as Elevating the head of
needed. bed 30 degrees aids in
swallowing and reduces
risk of aspiration.

Collaborative Dietitians have a greater

understanding of the
nutritional value of foods
• Consult
and may be helpful in
dietitian for
assessing specific ethnic
further
or cultural foods (e.g.,
assessment
"soul foods," Hispanic
and
dishes, kosher foods).
recommendati
ons regarding
food
preferences
and nutritional
support.

Dependent

• Review
laboratory
studies for
abnormalities. To aid regain fluid loss
and maintain fluid
• Administer balance in the body.
 enteral and IV
fluids as
indicated.

• Administer
anti-diarrheal To decrease
medications, gastrointestinal motility
as indicated and minimize fluid
losses.
NURSING CARE PLAN

Submitted by:
De Castro, Kim Domenique P.
BSNIV Group 9
Olivarez College - Parañaque