OUTCOME

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

Name: Aida Layug D> Potential/ P> After 2 hrs of Dx> To determine current E> After 2 hrs of
Readiness for nutritional status:
Age: 34 y/o nursing nursing
Enhanced >The client a.) Review Client’s > Provides
intervention the baseline for intervention the
Post NSD G4P4 Nutrition expresses knowledge of current
further teaching
willingness to nutritional needs and interventions.
client will client showed/
SUBJECTIVE: enhance nutrition b.) Assess eating patterns >Helps to identify
demonstrate demonstrated
“ Noodles palang kinain and food/fluid choices in specific strengths
ko eh” as verbalized by >The client’s behaviors to relation to any health- and weaknesses behaviors to
risk factors and health that can be
the client attitude towards
attain/maintain goals. addressed. attain/maintain
drinking is
OBJECTIVE:
congruent with appropriate Tx> To assist client to develop appropriate
-V/S BP- 120/70 mmHg plan to meet individual
health goals nutrition needs: nutrition
PR- 89 bpm (Input- 1700ml)
a.) Determine
RR- 24 bpm >to determine that
>consumes motivation/expectation
client is healthy
T- 37.1 ˚c for change and identify
adequate fluid
dietary changes
-I/O- 1700 ml/ 5X b.) Assist in
that may be
obtaining/review results helpful in
PHYSICAL of individual testing attaining health
ASSESSMENT: goals.
Edx> To promote optimum
-Firm and Contracted wellness:
Fundus
a.) Encourage eating high > to make a
roughage foods and sufficient nutrition
for the mother and
soups produce more
milk for the baby