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  • Assessment Planning Intervention Evaluation

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    Elaisa Mae Delos Santos
    31 views4 pages
    The document summarizes the nursing assessment, diagnosis, planning, intervention, and evaluation for a patient named R.S. over three visits. R.S. was initially assessed with inadequate food intake and weight loss, leading to a diagnosis of imbalanced nutrition. The goal was for R.S. to ingest appropriate calories, with interventions including daily weighing and providing nutrient-rich liquids. On a second visit, R.S. had pale skin and low hemoglobin, diagnosed as ineffective tissue perfusion due to low hemoglobin. The goal was to increase perfusion, intervening to increase iron intake. On a third visit, R.S. had fever, thirst, and weight loss, diagnosed as deficient fluid volume due to

    Original Description:

    case study

    Original Title

    NCP DM TYPE 1

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    The document summarizes the nursing assessment, diagnosis, planning, intervention, and evaluation for a patient named R.S. over three visits. R.S. was initially assessed with inadequate food intake and weight loss, leading to a diagnosis of imbalanced nutrition. The goal was for R.S. to ingest appropriate calories, with interventions including daily weighing and providing nutrient-rich liquids. On a second visit, R.S. had pale skin and low hemoglobin, diagnosed as ineffective tissue perfusion due to low hemoglobin. The goal was to increase perfusion, intervening to increase iron intake. On a third visit, R.S. had fever, thirst, and weight loss, diagnosed as deficient fluid volume due to

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    31 views4 pages

    Assessment Planning Intervention Evaluation

    Uploaded by

    Elaisa Mae Delos Santos
    The document summarizes the nursing assessment, diagnosis, planning, intervention, and evaluation for a patient named R.S. over three visits. R.S. was initially assessed with inadequate food intake and weight loss, leading to a diagnosis of imbalanced nutrition. The goal was for R.S. to ingest appropriate calories, with interventions including daily weighing and providing nutrient-rich liquids. On a second visit, R.S. had pale skin and low hemoglobin, diagnosed as ineffective tissue perfusion due to low hemoglobin. The goal was to increase perfusion, intervening to increase iron intake. On a third visit, R.S. had fever, thirst, and weight loss, diagnosed as deficient fluid volume due to

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 4

    Patient: R.

    ASSESSMENT
    Objective
    -

    Increased urine
    output (800cc)
    Weight loss
    (22.4kg)
    Reported
    inadequate food
    intake

    PLANNING
    Short term Goal
    After 8hrs of nursing
    intervention the patient
    will ingest appropriate
    amount of calories.

    INTERVENTION

    EVALUATION

    Wholly Compensatory

    The patient conditions


    maintained.

    DIAGNOSIS
    Imbalanced nutrition Less
    than body requirements
    related to Insulin
    deficiency.

    Weigh daily or as
    ordered
    Perform finger stick
    glucose testing
    Provide liquids
    containing nutrients
    and electrolytes
    Auscultate bowel
    sounds. Note report
    of abdominal pain,
    bloating, nausea
    and vomiting of
    undigested food.

    Patient: R.S

    ASSESSMENT
    Objective
    - Pale color of the
    skin and
    conjunctiva
    - 108 hemoglobin
    count
    - Capillary refill
    >4sec

    DIAGNOSIS
    Ineffective tissue
    perfusion r/t decrease
    hemoglobin concentration
    in blood.

    PLANNING

    INTERVENTION

    Short term Goal


    After 8hrs of nursing
    intervention the patient
    will demonstrate signs
    of increase perfusion.

    Wholly Compensatory
    - Increase oral fluid
    intake
    - Advise relatives to
    provide food rich
    in iron such as
    eggs, cereals,
    mashed and
    vegetables.
    - Include a source
    of vitamin C in the
    diet such as citrus
    juice.

    EVALUATION
    The patient conditions
    maintained.

    Patient: R.S

    ASSESSMENT
    Objective:
    - Elevated temp of
    38.4C
    - Increase urine
    output (700cc)
    - Sweating of the
    skin
    - Thirst
    - Weight loss
    (22.3kg)
    - Dry skin

    DIAGNOSIS

    PLANNING

    INTERVENTION

    Short term Goal


    After 8 hrs of nursing
    intervention the pt shall
    have verbalized
    understanding of
    causative factors and
    purpose of individual
    therapeutic
    interventions and
    medications.

    Wholly Compensatory
    - Encourage pt to
    increase Oral fluid
    intake.
    - Administer anti
    pyretic as ordered
    - Assess skin turgor
    or mucous
    membrane for signs
    of dehydration.

    EVALUATION
    The patient condition
    improved.

    Deficient fluid volume


    r/t intracellular
    dehydration secondary
    to DM I

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