Assessment Explanation of the Problem Objectives Nursing Interventions Rationale Evaluation
S>Di siya makakain nang
maayos at nanghihina paas verbalized by the significant other.
O>Weight loss note >Documented inadequate caloric intake >Easy fatigability observed >Reported altered taste sensation > Weakness of muscle required for mastication > Aphagia noted
Nursing Diagnosis: Imbalance nutrition: less than body requirements r/t insufficient nutrition intake secondary to decreased taste sensation
Since the client is unable to eat using mechanical mastication, she is required to have oral feedings via nasogastric tubing and since she is a geriatric client, her taste buds become less effective. Due to the existence of the NGT tube an unfamiliar or unpalatable food is entering the clients system. The content of the food is not enough to supply the metabolic needs leading to decreased strength and stamina. Thus, intake of insufficient nutrition leads to imbalance nutrition less than body requirements.
STO: After 2-3 hours of rendering effective nursing intervention the client will be able to demonstrate the following: a)Importance of nutritional intake b)Importance of maintaining body weight c)Verbalize understanding of causative factors when known and necessary interventions
LTO: After 2-3 days of rendering effective nursing intervention the client will be able to understood the following: a)Right amount of calorie intake b)Progressive weight gain toward goal c)To take vitamins regularly Dx: >Assess body mass index
>Asses nutritional intake
>Auscultation bowel sounds.
Tx: >Assist in performing oral hygiene
>Administer medications as ordered
>Assist in NGT feeding
Edx: >Encourage the significant others to feed nutritious foods
>Instruct to warm the feeding before
>To provide a general assessment of a persons body composition
>To know the intake of essential nutrients
> Bowel sounds are decreased or increased indicates a disturbance in digestive function
>Bad breath odor can reduce appetite.
>to prevent complications
>To satisfy hunger and increase the nutritional intake
>To increase influenced of persons taste about the importance of nutrition of the body
>to prevent gastrointestinal upset STO:GOAL MET if After 2-3 hours of rendering effective nursing intervention the client was able to demonstrate the following: a)Importance of nutritional intake b)Importance of maintaining body weight c) Verbalize understanding of causative factors when known and necessary interventions
LTO:After 2-3 days of rendering effective nursing intervention the client will be able to understood the following: a)Right amount of calorie intake b) Progressive weight gain toward goal c)To take vitamins regularly administering
>Instruct and emphasize the importance of hand hygiene
>To prevent microorganisms from entering the body through NGT feeding