| NURSING DIAGNOSIS
| SCIENTIFIC RATIONALE
| NURSING INTERVENTIONS
| NURSING CARE PLAN: IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS RELATED TO ANOREXIA, NAUSEA, AND ALTERED ABSORPTION AND METABOLISM SUBJECTIVE:“Diri na ako nakakakaon hin tuhay tikang jan nasakit ako. Baga diri man liwat ako gingugutom tapos kun nakaon liwat ako baga hin ginsusuka-suka ako ” as verbalized by the patient.“Nakakaabat gihap ako nga baga nanluluya tak kalawasan.” As verbalized by the patient.OBJECTIVE: * Weight of 120 lbs (baseline wt. 137.5) * Height of 5’5” * Wt loss of 17.5lbs (13%) * IBW of 136-149.6lbs * Patient was noted to be * Weak * Lethargic * Nauseated * Exhausted * With poor appetite * Irritable * cracked lips and dry mucus membrane * pale conjunctiva * Hemoglobin of 9g/dL * CBG of 76g/dL
| Imbalanced Nutrition: Less Than Body Requirements related to anorexia, nausea, bile stasis, and altered absorption and metabolism
| During the most severe phase of the Hepatitis B, when changes occur in the stomach or bowel, anorexia and nausea may be so extreme that oral intake of any kind is greatly reduced, leading to a common nursing diagnosis of Imbalanced nutrition. Reference:Medical Surgical Nursing, p.1142-Black & Hawk
| SHORT TERM:Within 8 hours ofeffective nursinginterventions, patientwill be able to manifest tolerance of feeding with no signs of nausea and vomiting as evidenced by: * Patient did not vomit during feeding * Patient did not complain of feeling of fullness * Patient has good appetite * Patient is no longer: * weak * Lethargic * Nauseated * Irritable * Blood glucose level in normal range: 110 mg/dlLONG TERM:After 3 days of nursing interventions the patient will be able to manifest progressive weight gain towards goal with normalization of laboratory values and no signs of malnutrion as evidenced by: * Increased weight from 120 lbs. to 126 lbs. *...
Please join StudyMode to read the full document