Question

Please help with the priority NANDA Nursing diagnosis, goal, intervention/rationale and evaluation for the patient.

Sallie Jefferies, 28-year-old patient, is at the obstetric clinic for a pregnancy visit. The physician informs the patient that her HIV screen test is positive. The patient has no evidence of AIDS. The nurse provides patient education regarding what HIV is and what the clinical management entails

Answer 1

NURSING DIAGNOSIS

1.Imbalanced nutrition less than body requirements related to altered ability to ingest ;nausea and vomiting and fatigue evidenced by lack of interest in food and altered taste sensation,abnormal laboratory results.

Outcome-Maintain weight or display weight gain toward desired goal.

Nursing interventions	Rationale
Assess the patients ability to taste and swallow	metallic or other taste changes caused by medications ,limiting the patient's ability to ingest food and reducing desire to eat.
Evaluate the weight and compare serial weights and anthropometric measurements	Indicator of nutritional adequacy of intake
Schedule medications between meals	Gastric fullness diminishes appetite and food intake
Provide rest periods before meals	Reduces stimulus of the vomiting center in the medulla
Record ongoing caloric intake	Identifies need for supplements

2.Knowledge deficit related to information misinterpretation as evidenced by questioning ,statement of misconceptions.

Outcome-Verbalize understanding of therapeutic needs,disease process and complications.

Nursing interventions	Rationale
Review the disease process and the future expectations	Provides knowledge base from which patient can make informed choices.
Review dietary needs and ways to improve intake	Promotes adequate nutrition necessary for healing support of immune system;enhances feeling of well being.
Discuss medication regimen, interactions and side effects	Enhances cooperation with or increases probability of success with therapeutic regimen
Identify signs and symptoms requiring medical evaluation like fever,weight loss chest pain	Early recognition of developing complications and timely interventions.
Identify community resources	Facilitate better care
Encourage activity and exercise at level that patient can tolerate	Stimulates release of endorphines in the brain,enhancing sense of well being
Stress necessity of continued health care and follow up	Provides opportunity for altering regimen to meet individual and changing needs.