CU-QMS-NURSING-0017

CAPITOL UNIVERSITY
COLLEGE OF NURSING

Name of Student: _________________________________________________ Date of Assignment: ________________________________

Name of Patient: _________________________________________________ Ward: ____________________ Bed No. ________________

NURSING CARE PLAN

ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND OBJECTIVES NURSING INTERVENTIONS AND EVALUATION
(Subjective & Objective Cues) (Problem and Etiology) RATIONALE
Subjective: Imbalanced nutrition less than Within 72 hours of nursing Provide a diet that meets patient daily At the end 72 hours of
body requirements related to intervention: caloric requirements. Daily caloric intake nursing intervention the
● Patient reported food intake intestinal obstruction; inability to ● Patient will exhibit goals were met.
depends on age, metabolic status, and
less than RDA (recommended absorb nutrients; insufficient intake
no further weight activity level.
daily allowances) ● Patient weight
loss Rationale: A diet meeting the patient’s
● Lack of interest in food stabilizes or
● Perceived inability to ingest ● Patient and family caloric requirements helps meet the increases.
food members will patient’s maintenance and ● Patient takes in
● Satiety immediately after express growth needs. enough calories
eating understanding of
● Abdominal pain or cramping and essential
total parenteral Record and describe food intake. Refer
● Lack of information, nutrients and
nutrition (TPN), if family members to a dietitian or
misinformation retains feedings.
appropriate, or nutritional support team for dietary ● Patient and family
demonstrate management. members
Objective: understanding of Rationale: A dietitian or nutritional demonstrate
other feeding support team can individualize the
● Body weight 20% or more understanding of
techniques essential patient’s diet within prescribed
under ideal weight nutritional
to daily nutritional restrictions.
● Capillary fragility principles and
requirements.
● Hyperactive bowel sounds; requirements,
diarrhea and steatorrhea ● Family members will • Promote adequate rest feeding
● Loss of body weight despite express willingness Rationale: To reduce fatigue and improve
to continue the techniques, and
adequate food intake the patient’s ability and desire to eat.
feeding regimen at special needs.
● Pale conjunctiva and mucous
membranes home. ● Family members
• Obtain and record the patient’s weight
● Poor muscle tone each morning before the first feeding. express
● Excessive loss of hair Rationale: To accurately monitor the willingness to
● Sore, inflamed buccal cavity response to therapy. continue the
feeding regimen
• Provide parenteral fluids, as ordered. at home.
Rationale: To ensure adequate fluid and
electrolyte levels.

• Monitor electrolyte values and report

abnormalities.
Rationale: Poor nutritional status may
cause electrolyte imbalances.

• Monitor and record the amount, color,

consistency, and presence of occult blood
in emesis and stools.
Rationale: Characteristics of vomitus and
stools provide clues to nutrient
absorption.

• If the patient is receiving tube feedings:

Use a continuous infusion pump, if
possible, to help prevent diarrhea,
fatigue, and stimulation of vagal
response.
Rationale: A continuous infusion pump
also helps prevent reduction in the cough
or gag reflex and overstimulation of the
stomach.

Check feeding tube placement before

each feeding.
Rationale: To verify tube placement in
the GI tract rather than in the lung.
Begin the regimen with small amounts
and diluted concentrations
Rationale: To decrease diarrhea and
improve absorption. Increase volume and
concentration, as tolerated.

Keep the head of the bed elevated during

feedings.
Rationale: To reduce the risk of
aspiration.

Teach the family member the correct

technique for tube feeding
Rationale: To ensure compliance with the
feeding regimen at home.

• If the patient is receiving TPN:

Carefully monitor delivery of TPN.
Rationale: To promote effective therapy
and prevent circulatory overload.

Monitor blood glucose level, urine

specific gravity, and urine glucose,
protein, and metabolite levels at least in
every shift.
Rationale: To detect metabolic
complications, osmotic diuresis,
hypoglycemia, and pulmonary edema.

Provide or assist with oral hygiene.

Rationale: To enhance the patient’s
comfort and improve appetite.
 Teach the family member the correct
technique for maintaining TPN infusion at
home.
Rationale: To ensure the patient family
member continues the feeding regimen
after discharge.

Issue: 05 April 2006 Revision Code : 003

CU-QMS-NURSING-0018