ASSESSMENT Subjective Ninggamay jud akong kinaon karon as verbalized by the patient.

Objective: Received patient lying on bed with ongoing #2 PNSS 1L regulated at 20gtts/ min with 700cc IVF level left running and infusing well at left metacarpal vein loss of weight observed lack of intake aversion to eating decreased subcutaneous fat/ muscle mass poor muscle tone

NURSING DIAGNOSIS Imbalance nutrition: less than body requirements related to altered intake/ absorption of nutrients

PLANNING After 8 hours of nursing intervention, the patient will be able to:

INTERVENTION Independent: >Monitored vital signs and recorded >Monitored intake and output >Ensured side rails up >Assessed weight, age, body built, strength, activity/ rest level and so forth >Promoted pleasant, relaxing environment, including socialization when possible >Prevented unpleasant odor/ sights. >Promoted adequate/ timely fluid intake >Encouraged frequent oral care

RATIONALE

EVALUATION After 8 hours of nursing intervention, the patient was able to: Goal met, verbalized understandi ng of causative factors when known and necessary intervention s Goal met, demonstrat ed behaviors, lifestyle changes to regain and/ or maintain appropriate weight

>for baseline data >for fluid and electrolyte balance >to provide safety > to provide comparative baseline >to enhance intake

Verbalize understanding of causative factors when known and necessary interventions Demonstrate behaviors, lifestyle changes to regain and/ or maintain appropriate weight

>may have a negative effect on appetite/ eating >Limiting fluids 1hour prior to meal decreases possibility of early satiety >to enhance appetite

pale conjunctiva pale mucous membranes abnormal laboratory findings body weakness noted

Vital Signs: Temp - 36.6 RR - 19 PR - 75 BP - 110/80

Dependent: >Administered pharmaceutical agents as indicated >Regulated IVF as ordered >Restricted any types of food as ordered >Prepared patient for possible laboratory followup/ surgery Collaborative: >Consulted dietitian/ nutritional team as indicated >Encouraged patient to choose foods that are appealing >Determined whether patient prefers/tolerates more calories in a particular meal >Encouraged use of sugar/honey in beverages if carbohydrates are tolerated well

>to promote wellness >to prevent cardiac overload >may cause intolerances/increase gastric motility >for diagnostic baseline data

>to implement interdisciplinary team management >to stimulate appetite >to enhance food satisfaction

>to stimulate appetite

ASSESSMENT

NURSING DIAGNOSIS Diarrhea related to inflammation or malabsorption of the bowel

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: Pime ko magkalibang ug basa as verbalized by the patient.

After 8 hours of nursing intervention, the patient will be able to: Verbalize understanding of causative factors and rationale for treatment regimen

Objective: Received patient lying on bed with ongoing #2 PNSS 1L regulated at 20gtts/ min with 700cc IVF level left running and infusing well at left metacarpal vein hyperactive bowel sounds upon auscultation 3-4 per day of loose liquid stools as patient verbalized pale looking

Demonstrate appropriate behavior to assist with resolution of causative factors (e.g. proper food preparation or avoidance of irritating foods)

Independent: >for baseline data >Monitored vital signs and recorded >Noted diet history >to assess causative factors >for fluid and >Monitored intake electrolyte balance and output >to promote return >Increase oral fluid to normal bowel intake functioning >Promoted the use >to decrease of relaxation stress/ anxiety techniques (e.g. progressive relaxation exercise, visualization techniques) >Reviewed >to assess laboratory work for electrolyte balance abnormalities Dependent: >Administered antidiarrheal medication as indicated

After 8 hours of nursing intervention, the patient was able to: Goal met, verbalized understandi ng of causative factors and rationale for treatment regimen Goal met, demonstrat ed appropriate behavior to assist with resolution of causative factors

>to decrease gastrointestinal motility and minimize fluid losses

Vital Signs: Temp - 36.6 RR - 19 PR - 75 BP - 110/80

>Administered enteral and IV fluids as indicated > Restricted solid food antake as indicated >Given medications as ordered >Prepared patient for possible laboratory examination (e.g. stool exam) Collaborative: >Consulted dietitian/ nutritional team as indicated >Assisted as needed with precare after each bowel movement >Encouraged oral fluids containing electrolytes such as juices, or commercial preperations as

>to maintain hydration/ electrolyte balance >to allow for bowel rest/ reduced intestinal workload >to treat infectious process, decrease motility,and/or absorb water >to assess the presence of fat, blood, infections, etc. in the stool > to implement interdisciplinary team management >to maintain skin integrity

>to maintain hydration

appropriate