Cues
Subjective: mahilig akong kumain ng taba Objective: -restless -loss of appetite -nausea and vomiting -muscle weakness
Nursing diagnosis
Imbalance nutrition less than body requirements related to disease process
Inference
Eating unhealthy foods such as fatty and salty foods
Objective
Goal: The client will have a adequate nutritional intake Short-term After 2 hours of nursing intervention the client will be able to verbalize understanding of causative factors when known and necessary interventions Verbalized that that the feeling of nausea and vomiting is lessened Long-term: After 1 week of nursing intervention the client will be able to: Demonstrate lifestyle changes to regain and maintain
Intervention
Independent: Assess the client dietary status
Rationale Provide a data about dietary status Information about other factors that may be altered to promote adequate dietary intake is provided
Evaluation Goal: partially met as manifested by the client ability to: verbalize understanding of causative factors when known and necessary interventions
Lodge inside the artery
Assess for factors contributing to altered nutritional intake (nausea and vomiting, depression)
Atherosclerosis
Hypertension
Provide patient food preferences within dietary restrictions
Thrombus
Stroke
Promote intake of low protein foods, low salt, low fat high fiber meals. (e.g. 1 cup of rice, 2 banana per meal) Limit the fluid intake
Increased dietary Verbalized that intake is that the feeling encouraged of nausea and vomiting is lessened Reduces source of restricted food and providing Demonstrate that proteins for the feeling of growth and nausea and healing vomiting is lessened.
Instruct to avoid food that increases
Avoid the increase of
appropriate weight
Demonstrate a progressive weight gain toward goal Demonstrate that the feeling of nausea and vomiting is lessened.
gastric motility (e.g. hot, cold, spicy, caffeinated beverages)
gastric motility
Promote a pleasant relaxing environment including socialization when possible Dependent: Administer medications as indicated Provide and implement dietary modifications Collaborative: Consult a dietitian as indicated Discuss the rationale of dietary restriction in relation to kidney disease
Cues
Subjective: ang sakit ng ulo ko na parang ako ay nahihilo Pale looking Weak in appearance Irritable
Nursing diagnosis
High blood pressure (HBP) or hypertension means high pressure (tension) On the arteries. Arteries are vessels that carry blood from the pumping heart to all the tissues and Organ of the body. High blood pressure does not mean excessive emotiona l tension, although hemotional tension and stress can temporarily increase blood pressure.
Inference
Objective
Short term goal: After 6 hrs. Of nursing intervention the client will have no elevated in blood pressure above normal limits and will maintain blood pressure within acceptable limits.
Intervention
Dependent: monitor BP q1
Rationale
Change in BP may indicates changes in patient status requiring promp attention.
Evaluation
Short term goal: After 6 hrs. Of nursing intervention the client will have no elevated in blood pressure above normal limits and will maintain blood pressure within acceptable limits. Long term goal : After 3 days of nursing intervention, the client adequate cardiac output and cardiac index
Maintained on moderate high back rest position
Long term goal : After 3 days of nursing intervention, the client adequate cardiac output Collaborative: and cardiac index
Encourage patient to decrease intake of caffeine, cola and chocolates.
It may decreases peripheral venous pooling that may be potentiated by vasodilators and prolonged sitting or standing Caffeine is a cardiac stimulant and may adversely affect cardiac function
Administer medicines as prescribed by the physician
To promote wellness.
