The patient presented with altered taste sensation and productive cough. Nursing interventions included assessing nutritional status, monitoring intake and output, providing oral care, and encouraging adequate nutrition and rest. After 8 hours, the patient demonstrated progressive weight gain and proper oral care, achieving the goal of balanced nutrition as shown by a 10% increase in weight and improved nutritional status.
The patient presented with altered taste sensation and productive cough. Nursing interventions included assessing nutritional status, monitoring intake and output, providing oral care, and encouraging adequate nutrition and rest. After 8 hours, the patient demonstrated progressive weight gain and proper oral care, achieving the goal of balanced nutrition as shown by a 10% increase in weight and improved nutritional status.
The patient presented with altered taste sensation and productive cough. Nursing interventions included assessing nutritional status, monitoring intake and output, providing oral care, and encouraging adequate nutrition and rest. After 8 hours, the patient demonstrated progressive weight gain and proper oral care, achieving the goal of balanced nutrition as shown by a 10% increase in weight and improved nutritional status.
The patient presented with altered taste sensation and productive cough. Nursing interventions included assessing nutritional status, monitoring intake and output, providing oral care, and encouraging adequate nutrition and rest. After 8 hours, the patient demonstrated progressive weight gain and proper oral care, achieving the goal of balanced nutrition as shown by a 10% increase in weight and improved nutritional status.
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Time Chart
7:00-3:00 am F> Imbalanced nutrition: Less than body requirements related to frequent cough as evidenced by reported altered taste sensation
D> Received lying in bed with an intact D5W @ 1L x 16 hours. With VS as follows: T-38C, PR- 110 bpm, RR-28 cpm, BP- 130/90 mmHg, SPO2- 92%. With productive cough. “Wala akong gana kumain at hindi ko malasahan”. A> Assessed weight, measure or calculate body fat. Documented nutritional status on admission, noting skin turgor, current weight and degree of weight loss, integrity of oral mucosa, ability or inability to swallow. Monitored I&O and weight periodically. Monitored laboratory studies: BUN, serum protein, and prealbumin. Provided oral care before and after respiratory treatments. Referred to dietician for any possible adjustments in dietary composition. Administered antipyretics as appropriate. Evaluated total daily food intake. Promoted pleasant relieving environment including socialization. Encouraged and provided for frequent rest periods. Encouraged patient to choose food or have family member to bring food that seems appealing and is not contraindicated
R> After 4 hours of nursing intervention, the patient was able to demonstrate progressive weight gain goal with normalization of laboratory values and be free of signs of malnutrition and importance of oral care
DATA GOALS/ ACTION/ NURSING RATIONALE RESPONSE &
Expected outcomes INTERVENTIONS EVALUATION Subjective findings: STG: within Dxtc: After ___8___hr/s of NI, “Wala akong gana ___4___hour/s of NI the Assessed weight, Established baseline the patient was able to kumain at hindi ko patient will be able to measure or calculate parameter demonstrate progressive malasahan” demonstrate progressive body fat weight gain goal and weight gain goal and Documented patient’s Useful in measuring proper oral care Objective findings: proper oral care nutritional status on effectiveness of as manifested by -With VS as follows: as manifested/evidenced admission, noting skin nutritional and fluid identified behaviour, T-38C, PR- 110 bpm, by: identifying behaviour, turgor, current weight support lifestyle changes to RR-28 cpm, BP- lifestyle changes to and degree of weight maintain proper nutrition 130/90 mmHg, maintain proper nutrition loss, integrity of oral and stressed the SPO2-92% and importance of oral mucosa, ability or importance of oral care - with productive care inability to swallow STG: fully/partially/un cough Monitored I&O and MET LTG: after _3__days of weight periodically Useful in measuring Focus/ Nursing Dx: NI the patient will be able effectiveness of (PE/S) to: achieve well-balanced nutritional and fluid After ___8___hr/s of NI, Imbalanced nutrition: nutrition Monitored laboratory support the patient was able to Less than body as manifested by: studies: BUN, serum Low values reflect achieve well-balanced requirements related increase in weight of protein, and malnutrition and nutrition to frequent cough as 10% of patient’s weight prealbumin indicate need for as manifested by evidenced by and progressive intervention and increase in weight of reported altered taste nutritional status change in therapeutic 10% of patient’s weight sensation Txc: regimen and progressive Provided oral care nutritional status before and after Reduces bad taste left STG: fully/partially/un respiratory treatments from sputum or MET medications used for respiratory treatments that can stimulate the Referred to dietician vomiting center for any possible Provides assistance in adjustments in dietary planning a diet with composition nutrients adequate to meet patient’s metabolic requirement and dietary Administered preferences antipyretics as Fever increases appropriate metabolic needs and therefore calorie Evaluated total daily consumption food intake Reveals possible cause of malnutrition changes that could be made in patient’s Edx: intake Promoted pleasant relieving environment This promotes including socialization comforts to the patient Encouraged and and encourages good provided for frequent eating habit rest periods Helps conserve energy, especially when metabolic requirements are Encouraged patient to increased by the fever choose food or have To stimulate the family member to appetite of the patient bring food that seems appealing and is not contraindicated
