Patient: X Medical diagnosis: Cellulitis in right lower extremity and Diabetes Melllitus type 2.

Address: Bitaog, Bansalan, Davao Su Attending physician: Dr. Sarno

Age: 79 yrs.
DATE/TIME CUES
SUBJECTIVE:
F “permi ko
E gutomon”
B As verbalized.
R OBJECTIVE:
U  restlessnes
A noted;
R  body
Y weakness
noted;
Chief complaint: Wound Swelling at Right Leg
Nutritional imbalance
NEE NSG. DIAGNOSIS OBJECTIVE OF NSG. EVALUATION
D CARE INTERVENTIONS
Within my 8 hours
N Nutritional imbalance: span of care the 1. Established rapport to February 5,
U less than body patient will be able our patient. 2010
T requirements related to to: ® To gain their trust and “GOAL
R increase metabolic a.) Improve cooperation. PARTIALLY
I demand appetite 2. Monitor VS q4 MET”
T Secondary to diabetes b.) Verbalize ® to identify patients
I mellitus type 2 understandi health status After our 8 hours of
O ng of proper 3. Determine ability to implementing
N diet. chew, swallow, and nursing

 pale A taste. interventions, our

05, conjunctiva L ® factors that can affect patient was able to:

and mucous - ingestion and/or a.) verbalized

membranes M digestion of nutrients. understanding of

2010 E 4. Discuss eating habits, proper diet.
T including food
A preferences,

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  VS: B intolerance/aversions.
O ® to appeal to clients
Temp.= 38◦ C L likes/desires.
PR= 111 bpm I 5. Assess weight, age,
RR= 28 cpm C body build strength,
BP= 150/80 activity/rest level, and
mmHg P so forth.
A ® provides comparative
T baseline.
T 6. Auscultate bowel
E sounds.
R ® to identify if its in
N normal range
7. Use flavoring agents
such as lemon and
herbals.
® if salt is restricted; to
enhance food
satisfaction and
stimulate appetite.
8. Promote
adequate/timely fluid

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intake.
® Limiting fluids 1 hour
prior to meal decrease
possibility of early
satiety.
9. Promote pleasant,
relaxing environment,
including socialization
when possible to.
® To enhance intake.
10. Consult nutritionist.
® identify appropriate
diet.
11. Weigh weekly
® to monitor
effectiveness of efforts.

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