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Nursing Care Plan: Saint Louis University School of Nursing Bonifacio Street, Baguio City

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SAINT LOUIS UNIVERSITY

SCHOOL OF NURSING
Bonifacio Street, Baguio City

Nursing Care Plan

Submitted to:
Mrs. Sharon Hogat

Submitted by:
Barao, Jasper Nazarene
F. NCP PROPER

CUES EXPLANATION OF GOALS AND INTERVENTIONS RATIONALE EVALUATION ACTUAL


THE PROBLEM OBJECTIVES CRITERIA EVALUATION
Problem: Imbalanced Nutrition: LTO: Dx: FULLY MET:
Gastric Mass Less than Body After 3 days of 1. Vital signs assessed 1. To establish baseline The client will
Requirements is the nursing and recorded data consume 100% of
S: state in which an interventions, meal served.
-“Wala akong individual, who is not client will Tx:
ganang kumain” NPO, experiences or is consume 100% of 1. Administered 1. Omeprazole is anti-
-“Wala pang at risk for inadequate meal served. medications like emetic since the client PARTIALLY
kalahati ang intake or metabolism Omeprazole and had vomiting episodes; MET:
nauubos ko sa of nutrients for STO: Domperidone Domperidone is an anti- The client will
kinakain ko” metabolic needs with After 8 hours of ulcer consume 50-75%
or without weight loss. nursing 2. Assessed general and 2. To identify deviations of meal served.
O: Nutrition has an interventions, nutritional status, from the norm and to
-With poor appetite impact on the patient’s client will have ability to consume meal establish baseline
consuming 25% of immune function and small frequent served parameters NOT MET:
meal served outcome of cancer feeding. 3. Checked skin turgor 3. To check the The client will still
-Refuses other meal treatments. Adequate hydration status of the consume 25% of
served nutrition can minimize client meal served.
-Prefers to stay on the adverse effects of 4. Explored specific 4. To identify eating
bed all the time treatments, decrease eating habits practices that may need
-No difficulty in treatment-related to be corrected and
swallowing or symptoms, and provides insight into
chewing improve quality of life. dietary interventions
-Current weight if (Carpenito-Moyet, L. that may appeal to
decreased from 50 Handbook of Nursing client.
kg to 40 kg upon Diagnosis,
admission 12thed.(2008). 5. Check the ability to 5. To check the factors
-BMI= 17.7 LippincottWilliams chew or swallow that affect ingestion and
-With skin turgor of and Wilkins) /or digestion of
3 seconds nutrients.
-with initial vital 6. Evaluated total daily 6. To reveal possible
signs of: food intake. cause of malnutrition
BP= 140/90 mmhg and changes that could
PR= 90 bpm be made in client’s
RR= 16 cpm intake.
T= 36.4 C 7. Provide a pleasant 7. A pleasing
SpO2= 93% environment atmosphere helps in
decreasing stress and is
Nursing Diagnosis: more favorable to
Imbalanced eating.
Nutrition: less than Ed:
body requirements 1. Instructed to have 1. Eating small, frequent
related to biological small, frequent feeding. meals lessens the feeling
factors of fullness and decreases
the stimulus to vomit.

2. Instructed adequate 2. To reduce possibility


and timely fluid intake, of early satiety
limit fluids 1 hour prior
to meal
3. Discouraged 3. These beverages will
caffeinated or decrease hunger and
carbonated beverages. lead to early satiety.

4. Taught significant 4. Appeals to client


others on proper food tasks, and enhances
preparations with intake
variety and palatability
RERERENCES:
Kaufman, J. et al (2005, April 4). Gastric Mass. Medscape. Retrieved from https://www.medscape.com/viewarticle/496199_2
Imbalanced Nutrition: Less Than Body Requirements ? Nursing Diagnosis & Care Plan. (2017, September 24). Retrieved from https://nurseslabs.com/imbalanced-
nutrition-less-body-requirements/

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