Nursing Diagnosis: Imbalanced Nutrition: less than body requirements as evidence by lack of food interest, decreased amount of food intake, altered taste sensation, and is observably thin.
Assessment Data
(include both objective and subjective data if relevant) Resident’s Strengths Resident Goals/Outcomes Nursing Interventions
(How will you facilitate your resident reaching the stated goals?) Theoretical Rationale for Nursing Interventions
(Cite your reference source) Evaluation of Resident Goals/Outcomes
Consistently eats less meats and vegetables (RC, personal correspondence, October 5th, 2015).
Production of thick mucus occurs while eating, making it difficult for resident to swallow (RC, personal correspondence, October 12, 2015). …show more content…
Nurse will encourage resident to eat at least 50% of meal; every shift.
Nurse will offer higher caloric items every shift. Improving taste perception results in improvement of food intake and appetite. Seasoned foods, differently textured food increases taste perception (Potter and Perry, 1245).
Difficulty swallowing, dysphagia, can cause aspiration pneumonia, dehydration, and weight loss. Dysphagia screening identifies problem and improves the quality of care (Potter & Perry, 1010).
A lack of adequate nutrition reduces the body’s immune system and impairs wound healing. (Potter & Perry, 405).
Downward trends demonstrate serious reduction in nutritional reserves. (Potter & Perry, 496).
A nutritional diet and fluid balance reduces the risk of infection and is essential for a patient with nutritional imbalance. (Potter & Perry, 407).
This resident gets frequent skin tears, therefore, calories are important. Calories provide the energy needed for wound healing (Potter & Perry, 1186). Goal met: resident ate more vegetable and meat items; when salt or butter was added to the food.
Goal met: resident was observed by speech …show more content…
Nursing diagnosis: Impaired physical mobility as evidence by difficulty turning and limited range of motion.
Assessment Data Strengths Resident Goals/Outcomes Nursing Interventions Theoretical Rationale for Nursing Interventions Evaluation of Goals/Outcomes
During transfer resident states, “I am uncomfortable” (RC, personal correspondence, October 5 2015).
Resident is unable to assist caregivers when transferring (RC, personal correspondence, September 14, 2015).
Resident is prone to skin being teared when being transferred (RC, chart reviewed, September, 2015).
Erythemic skin lesion on his buttock. Charge nurse reports that the resident gets these lesions frequently (RC, personal correspondence, September 25th, 2015).
When assisting the resident with a jacket change; he is unable to lift his right arm to get his jacket on (RC, personal correspondence, October 5th, 2015).
During a-depend change, resident was instructed to bend his legs. Resident completed this task; got tired and laid his legs flat (RC, personal correspondence, September 25, 2015). R.C. is able to verbalize when he’s in pain.
Able to lean forward, when
Assessment Data
(include both objective and subjective data if relevant) Resident’s Strengths Resident Goals/Outcomes Nursing Interventions
(How will you facilitate your resident reaching the stated goals?) Theoretical Rationale for Nursing Interventions
(Cite your reference source) Evaluation of Resident Goals/Outcomes
Consistently eats less meats and vegetables (RC, personal correspondence, October 5th, 2015).
Production of thick mucus occurs while eating, making it difficult for resident to swallow (RC, personal correspondence, October 12, 2015). …show more content…
Nurse will encourage resident to eat at least 50% of meal; every shift.
Nurse will offer higher caloric items every shift. Improving taste perception results in improvement of food intake and appetite. Seasoned foods, differently textured food increases taste perception (Potter and Perry, 1245).
Difficulty swallowing, dysphagia, can cause aspiration pneumonia, dehydration, and weight loss. Dysphagia screening identifies problem and improves the quality of care (Potter & Perry, 1010).
A lack of adequate nutrition reduces the body’s immune system and impairs wound healing. (Potter & Perry, 405).
Downward trends demonstrate serious reduction in nutritional reserves. (Potter & Perry, 496).
A nutritional diet and fluid balance reduces the risk of infection and is essential for a patient with nutritional imbalance. (Potter & Perry, 407).
This resident gets frequent skin tears, therefore, calories are important. Calories provide the energy needed for wound healing (Potter & Perry, 1186). Goal met: resident ate more vegetable and meat items; when salt or butter was added to the food.
Goal met: resident was observed by speech …show more content…
Nursing diagnosis: Impaired physical mobility as evidence by difficulty turning and limited range of motion.
Assessment Data Strengths Resident Goals/Outcomes Nursing Interventions Theoretical Rationale for Nursing Interventions Evaluation of Goals/Outcomes
During transfer resident states, “I am uncomfortable” (RC, personal correspondence, October 5 2015).
Resident is unable to assist caregivers when transferring (RC, personal correspondence, September 14, 2015).
Resident is prone to skin being teared when being transferred (RC, chart reviewed, September, 2015).
Erythemic skin lesion on his buttock. Charge nurse reports that the resident gets these lesions frequently (RC, personal correspondence, September 25th, 2015).
When assisting the resident with a jacket change; he is unable to lift his right arm to get his jacket on (RC, personal correspondence, October 5th, 2015).
During a-depend change, resident was instructed to bend his legs. Resident completed this task; got tired and laid his legs flat (RC, personal correspondence, September 25, 2015). R.C. is able to verbalize when he’s in pain.
Able to lean forward, when