Submitted to: Mrs. Claire Castro, RN Submitted by: Butch V.

Costales, UDM-SN

Clinical Instructor
 OUTCOME
NURSING BACKGROUND
CUES/DATA IDENTIFICATION NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS ANALYSIS
&PLANNING

Name: Estelita Hagler D> Readiness P> After 1 hr of Dx> To determine current E> After 1 hr of
for Enhanced nutritional status:
Age: 27 y/o nursing nursing
Nutrition >The client a.) Review Client’s > Provides
intervention the baseline for intervention the
Post LTCS expresses knowledge of current
further teaching
starvation to nutritional needs and interventions.
client will client understood
OB code: G1P1 enhance nutrition b.) Determine patterns of >Helps identify
understand how how and when to
hunger and satiety strengths and
SUBJECTIVE: >The client’s weaknesses in
and when to attain attain adequate
eating patterns and
“ Gusto ko ng kumain, attitude towards
adequate nutrition potential for nutrition by
pwede na ba?” as eating is Tx> To assist client to develop change.
verbalized by the client plan to meet individual
congruent with verbalizing that
needs:
(-)Flatus health goals
>to determine that she needs to fart to
a.) Determine
(-)Bowel Movement client is healthy
>consumes motivation/expectation be able to eat.
and identify
OBJECTIVE: for change dietary changes
adequate fluid via
that may be
-V/S BP- 90/60 mmHg IV route; b.) Assist in helpful in
maintenance of obtaining/review results attaining health
PR- 79 bpm of individual testing goals.
1000ml every 6
RR- 18 bpm hours D5NR Edx> To promote optimum
wellness:
T- 36.6 ˚c
a.) Discuss the importance > To explain the
IVF-q6 ō 1000ml of NPO to the client’s temporary
D5LR/D5NR current status malfunctioning of
-I/O- 4000 ml/ FC gastrointestinal
b.) Educate the client that tract because of
she needs to have (+) operation and
flatus to be able to eat

OUTCOME
NURSING BACKGROUND
CUES/DATA IDENTIFICATION NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS ANALYSIS
&PLANNING

Name: Estelita Hagler D> Readiness P> After 30 mins. of Dx> To develop plan for > Provides E> After 30 mins.