Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

“I do not like the food here”

“I cannot eat the stuff they give it.  It’s terrible”

Objective

Decreased input

Ate only about 25% of breakfast tray.

Pt complains of nausea

Problem

Imbalance nutrition: less than body requirements

Long Term:

Client will identify nutritional requirements and recognize factors leading to being underweight by the time of discharge.

1.        Provide companionship while eating to encourage eating because patients will often eat more if other people are present at meal time (Ackley & Ladwig, 2008, p 577).

Goal still in progress. Patient seemed more willing to eat with student nurse present in the room, however complained of pain and not willing to eat due to pain.

Continue to accompany patient during meal times.  Administer pain medication before meals if possible to decrease amount of pain.

R/T

nausea, vomiting

Short Term:

Client will consume at least 50% of breakfast, lunch and dinner trays at the end of the day.

1.        Monitor food intake and record any food intake less than 50% because might need to discuss with dietitian (Ackley & Ladwig, 2008, p576).

2.        Administer antiemetic medicine prn to decrease nausea when eating and with medication intake so that the patient is more willing to eat (Ackley & Ladwig, 2008, p 563).

1.      Goal not met- Patient did not eat more than 50% of breakfast and lunch trays.

2.      Goal met.  Administered antiemetic with pain medication during breakfast.

1.       Will get order to have dietitian to come in and evaluate to determine other foods choices for patient.

2.      Continue to administer antiemetic as needed for c/o nausea.

AEB

patient stating “I cannot eat anything they give me.”