NURSING CARE PLAN (NURSING PROCESS)

ASSESSMENTS ANALYSIS GOALS INTERVENTIONS EVALUATIONS WITH

SUPPORTING
OBSERVATIONS
Data Collected Nursing Diagnosis Long Term & Short Term Nursing Actions and
Scientific Rationale with
Cited References
Evaluation of goals:
continue, Modify,
Discontinue Plans

Subjective:
Patient states, I cant wait
until I am able to eat
something. I feel like I
havent had any food in a
decade. I will definitely be
glad when the doctors
come in to see me.

Objective:
74 year old male came to
the ED complaining of
dizziness. Patient has
hypotension, lumbago,
renal failure, metabolic
acidosis, NPO, A&Ox3, has
unsteady gait with a can
for an assistive device,
right illeostomy draining
with bloody green fecal
(changes/empties bag
himself), irritable bowel
syndrome, bowel
obstruction, bilateral scds,
uses urinal, wears seeing

Imbalanced nutrition, less
than body requirement
related to inability to
ingest food because of
diet restrictions of NPO
status as evidenced by loss
of weight

Long Term:
Patient will gain 2 pounds
per week for the next 6
weeks

Long Term:
The patient indicate the
understanding of
significance of nutrition to
healing process and
general health within 1
week after discharge

Short Term:
The patient will
demonstrate no signs or
symptoms of malnutrition
by time of discharge from
treatment

Short Term:
The patient will consume
the prescribed number of
daily calories for breakfast
tomorrow morning

1) Intervention:
Keep strict documentation
of intake, output, and
calorie count.

Rationale:
This is necessary to make
an accurate nutritional
assessment and maintain
patient safety.

2) Intervention:
Weigh patient daily

Rationale:
Weight loss or gain is
important assessment
information

3)Intervention:
Determine the patients
likes and dislikes, and
collaborate with
dietitian to provide
favorite foods.

The patient has not shown
an adequate increase in
weight for 3 weeks,
continue goal

The patient indicated the
correct understanding of
the significance of
discharge, discontinue
plan

The patient continues to
demonstrate s/s of
malnutrition at this time,
modify plan and re-
evaluate in 1

The patient has consumed
the prescribed number of
calories this morning, goal
complete, discontinue
plan
glasses, (L) eye blind,
hearing impairment,
history of multiple hernia
repairs, history of multiple
DVTs, acute venous
embolisms, thrombosis,
Oxygen @ 3L via NC, right
chest mediport.

Height: 5.9
Weight: 179 lbs

Allergies: NKA

Abnormal Lab Values
Albumin: 2.9 (L)
Calcium: 8.3 (L)
Phosphorus: 2.1 (L)
INR: 4.03 (H)
RBC: 3.11 (L)
HGB: 8.3 (L)
HCT: 27.1 (L)

Vital Signs
B/P: 133/73
PULSE OX: 98%
HEART RATE: 86
TEMPERATURE: 36.4


Rationale:
The patient is more
likely to eat foods that
he or she particularly
enjoys.

4) Intervention:
Ensure that the patient
receives small, frequent
feedings, including a
bedtime snack, rather
than three larger meals.

Rationale:
Large amounts of food
may be objectionable,
or even intolerable, to
the patient.

5) Intervention:
Administer vitamin and
mineral supplements
and stool softeners or
bulk extenders, as
ordered by physician.

Rationale:
This will prevent patient
from becoming
constipated and assist
with his colon issues.
6) Intervention:
Stay with patient during
meals

Rationale:
To assist as needed and
to offer support and
encouragement.

7) Intervention:
Monitor laboratory
values, and report
significant changes to
physician.

Rationale:
Laboratory values
provide objective data
regarding nutritional
status.

8) Intervention:
Explain the importance
of adequate nutrition
and fluid intake.

Rationale:
The resident may have
inadequate or
inaccurate knowledge
regarding the
contribution of good
nutrition to overall
wellness.

9) Intervention:
Collaborate with a
registered dietician to
ensure adequate nutrition.

Rationale:
Adequate and correct
eating will help the patient
gain weight at an
considerable rate without
doing any further damage.

10) Intervention:
Auscultate bowel sounds

Rationale:
Bowel inflammation or
irritation may accompany
intestinal hyperactivity,
water absorption, and
diarrhea.

11) Intervention
Monitor Hb and Albumin

Rationale:
These labs indicate
adequate protein to the
immune system


REFERENCES CITED

Nursing Diagnoses:
Definitions and
Classification 2012-2014
2012, NANDA

Nutrition support in
critically ill patients:
Parenteral nutrition.
(2011). Parsons, P. E., &
Lipman, T. O.