ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
Objective Data: Imbalanced Demonstrate Measure dietary intake by The client
Nausea/ Nutrition: progressive calorie count. shows a
vomiting Less Than weight gain Weigh as indicated. Compare progressive
Weight Body toward goal changes in fluid status, recent weight gain
loss Requirements with patient- weight history, skinfold with
Pale related to appropriate measurements. appropriated
nausea/vomiti normalization Encourage patient to eat; normalized
ng, of laboratory explain reasons for the types laboratory
indigestion as values. of diet. Feed patient if tiring values.
evidenced by Experience no easily, or have SO assist
weight loss further signs of patient. Include patient in The client
Changes in malnutrition. meal planning to consider has
bowel sounds his/her preferences in food shown/experi
and function. choices. enced no
Encourage patient to eat all further signs
meals including of
supplementary feedings. malnutrition.
Give small, frequent meals.
Provide salt substitutes, if
allowed; avoid those
containing ammonium.
Restrict intake of caffeine,
gas-producing or spicy and
excessively hot or cold foods.
Suggest soft foods, avoiding
roughage if indicated.
Encourage frequent mouth
care, especially before meals.
Promote undisturbed rest
periods, especially before
meals.
Recommend cessation of
smoking. Provide teaching on
the possible negative effects of
smoking.
Monitor laboratory studies:
serum glucose, prealbumin
and albumin, total protein,
ammonia.
Maintain NPO status when
indicated.
Refer to dietitian to provide
diet high in calories and
simple carbohydrates, low in
fat, and moderate to high in
protein; limit sodium and fluid
as necessary. Provide liquid
supplements as indicated.
Provide tube feedings, TPN,
lipids if indicated.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
Objective Data: Risk for Maintain skin Inspect pressure The patient has
Edema impaired skin integrity. points and skin maintained skin
Yellowish integrity as Identify individual surfaces closely and integrity.
skin evidenced by risk factors and routinely. Gently The patient has
Skin poor skin demonstrate massage bony identified the
discoloratio turgor, behaviors/technique prominences or individual risk
n and rashes skeletal s to prevent skin areas of continued factors and has
Swollen prominence, breakdown. stress. Use of demonstrate
belly presence of emollient lotions behaviors/techniques
edema, and limiting use of to prevent skin
swollen belly soap for bathing breakdown.
(ascites) may help.
ecchymosis Encourage and
and petechiae assist patient with
reposition on a
regular schedule.
Assist with active
and passive ROM
exercises as
appropriate.
Recommend
elevating lower
extremities.
Keep linens dry and
free of wrinkles.
Suggest clipping
fingernails short;
provide
mittens/gloves if
indicated.
Provide perineal
care following
urination and bowel
movement.
Use alternating
pressure mattress,
egg-crate mattress,
waterbed,
sheepskins, as
indicated.
Use calamine
lotion and provide
baking soda baths.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
Objective Data: Ineffective Maintain effective Monitor respiratory rate, The patient
Fatigue Breathing respiratory pattern; depth, and effort. has
Labored Pattern as be free of dyspnea Auscultate breath sounds, maintained
breathing evidenced by and cyanosis, with noting crackles, wheezes, effective
Decreased dyspnea/labored ABGs and vital rhonchi. respiratory
lung breathing and capacity within Investigate changes in level pattern; free
expansion decreased acceptable range. of consciousness. of dyspnea
Intra- energy Keep head of bed elevated. and
abdomina Position on sides. cyanosis,
l fluid Encourage frequent with ABGs
collection repositioning and deep- and vital
(ascites). breathing exercises and capacity
coughing exercises. within
Monitor temperature. Note acceptable
presence of chills, increased range.
coughing, changes in color
and character of sputum.
Monitor serial ABGs, pulse
oximetry, vital capacity
measurements, chest x-rays.
Provide supplemental O2 as
indicated.
Demonstrate and assist with
respiratory adjuncts:
incentive spirometer.
