LIST OF NURSING DIAGNOSIS

Nursing Diagnosis Cues

1. Risk for Imbalanced Subjective:
Nutrition: Less than body - “Instead na magluto ay parang mas kailangan ko ng time na gumawa ng mga requirements at matulog na lang. Parang okay na din kumain
requirements related to kahit instant basta’t makakain at makapasok sa school na may laman ang tiyan,” as verbalized by client.
poor dietary habits - The patient claimed that she has been experiencing unexplained fatigue.
Objective:
- With BMI of 19.30, the client is nearly considered as underweight considering that she is 5’4” and weighs 51 kgs.
- The client consume high levels of monosodium glutamate from instant foods
- The patient has dry, coarse hair, and brittle nails.
- Limited nutrient-rich food intake due to absence of low nutrient-dense foods in the client’s diet
- Low salience of the problem that consumption of instant foods may lead to negative effects to the client’s general health status
2. Risk for Constipation related Subjective:
to water & fiber intake - “Dahil maraming ginagawa na din kasi hindi ko namamalayang ‘di na ako nakakainom ng maraming tubig tas mag-isa ko lang sa
boarding house kaya kapag ubos ang water jug, hindi ko naaasikasong magparefill,” as verbalized by patient.
- Patient verbalizes that she has episodes of difficulty in defecating.
Objective:
- As observed, the client has distended abdomen and upon palpation, the patient has a tender abdomen without palpable muscle
resistance. Through percussion, dull sound is heard most on her abdomen.
- Her sample stool is dry-hard.
- The patient has inadequate physical activity.

PRIORITIZATION
CARE PLAN
Nursing Diagnosis
Risk for Imbalanced Nutrition: Less than Body Requirements related to poor dietary habits

Explanation of the Problem

Risk for Imbalanced Nutrition: Less than Body Requirements according to NANDA is the increased chance of less than adequate intake or absorption of food or
nutrients. This includes poor eating habits like under-eating, not having enough of the healthy foods we need each day eating foods which are low in fibre, high in
fat, salt and/or sugar. These unhealthy eating habits can affect our nutrient intake, including energy, protein, carbohydrates, essential fatty acids, vitamins and
minerals as well as fiber and fluid. In all cases, social and environmental issues are one of the contributing factors of an individual’s nutritional needs. According to
Moufis, F. (2017), teenagers, especially students often miss meals and prefer to choose the quick pick-me-up provided by nutritionally deficient snacks and junk
food. Also, easy access to food stalls, fast foods chains, and super markets also contribute to their bad nutritional lifestyle. This is evident to the patient’s case who
is a nursing student and living in a dorm nearby several fishball stands, fast food chains, and etc. She is fond of eating chips, cup noodles, and canned goods since
these are easy to prepare. With the reasons mentioned, the patient has a high chance of inadequate nutrition/undernourishment.
 OBJECTIVES INTERVENTIONS RATIONALE EVALUATION, SUGGESTIONS, &
MODIFICATIONS
Long Term Objective: After 72 hours Dx: Weigh at regular intervals and Useful in determining caloric needs,
LTO:
of nursing intervention, the client will document results setting weight goal and evaluating
be able to demonstrate behaviors, adequacy of nutritional plan. Goal is fully met if after 72 hours of nursing
lifestyle changes to regain and intervention, the client will be able to
maintain appropriate nutrition intake Auscultate for bowel sounds. Hypoactive or diminished bowel sounds
demonstrate 5 behaviors and lifestyle changes to
may reflect decrease gastric motility and
Short Term Objectives: constipation related to decrease amount of regain and maintain appropriate nutrition intake
After 16 hours of nursing fluid intake, activity and poor food Goal is partially met if after 72 hours of
interventions, the client will be able to: choices.
nursing intervention, the client will be able to
a. Verbalize the importance of
eating nutritious food choices Assess the dietary intake of the client on her Unhealthy eating practices may need to be demonstrate at least 2 behaviors and lifestyle
on her own words routine food intake and take note any degree addressed and corrected to provide insight changes to regain and maintain appropriate
b. Shows willingness to change of difficulty with eating. into dietary interventions appealing to nutrition intake
behavior or lifestyle to client.
maintain appropriate weight. Goal is not met if after 72 hours of nursing
c. States understanding on the Assess patient’s perspective and feeling Various psychological, psychosocial, intervention, the client will not be able to
appropriate interventions to towards eating and food. religious, and cultural factors determine demonstrate any behaviors and lifestyle changes
achieve dietary plan. the type, amount, and appropriateness of to regain and maintain appropriate nutrition
food utilized.
intake
Observe body build To determine if the body composition is STO:
within the expected limits Goal if fully met if the client will be able to
verbalize in her own words the importance of
Tx: Promote good oral hygiene It enhances good appetite and better taste eating nutritious food, shows willingness to
of the food change in behavior or lifestyle to maintain
appropriate weight and was able to state her
Assist in devising a dietary plan that meets Ensures that devised plan has appropriate understanding on the appropriate interventions
recommended dietary allowances food choices based on dietary guidelines. to achieve dietary plan.
Ed: Encourage client to have a rest period Promotes comfort and helps to relieve Goal is partially met if the client will be able to
at least an hour before and after meals. tardiness. It also provides opportunity to verbalize in her own words the importance of
increase her caloric intake. eating nutritious food but does not show any
willingness to change her behavior or lifestyle to
maintain appropriate weight and does not
Encourage exercise Metabolism and utilization of nutrients understands the appropriate interventions to
are improved by activity. achieve dietary plan
Goal is not met if the client will not be able to
Determination of type, amount, and
Encourage patient participation in recording pattern of food or fluid intake as verbalize in her own words the importance of
food and fluid intake using a daily log facilitated by accurate documentation by eating nutritious food, does not show any
patient as the intake occurs; memory is willingness to change in behavior or lifestyle to
insufficient. maintain appropriate weight and was not able to
state her understanding on the appropriate
interventions to achieve dietary plan.