# data[].attributes.body
Pt will display normalization of laboratory values and be free of signs of malnutrition until Feb. 18th.

Evaluation
GOAL PARTIALLY MET
On January 18th: Albumin WNL, low sodium, low Hgb suggesting iron deficiency

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Assist with or encourage pt to complete oral care after meals and at bedtime (rationale: empowers pt and also prevents the overgrowth of bacteria in oral cavity)

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Pt will display timely healing of incisions and remain free from pressure sores until Feb. 19th

Evaluation
GOAL MET!
Pt remained free from skin breakdown in the perineal area, remained free from pressure sores, and pt's incision site demonstrated healthy healing according to REEDA evaluations

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Pt will rate pain <5 by noon on Feb. 18th and 18th. This will be measured using the pain scale.

Evaluation
GOAL MET - pain medication was given in a timely manner each day and pt rated pain <5 by noon each day

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Pt will display laboratory results within normal range for individual by February 18th, 2022

Evaluation
Goal partially met - Na+ was low on Feb. 18th, but chloride was WNL when it was low on Feb. 16th

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Pt will complete 2 tasks independently on Feb. 17th and 18th
Evaluation
GOAL PARTIALLY MET - pt ate independently (fluid diet) as well as independently completed oral care on Feb. 18th

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Support independance in activities as much as possible (Rationale: empowers pt) (Unbound Medicinc, 2022e)

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Help pt identify strengths and aspects of self that can be valued. (Unbound Medicine, 2022e)

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Assess negative moods or self-talk (feelings of unimportance and/or saying negative things about one's self can contribute to low self-esteem) (Unbound Medicine, 2022e)

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Situational Low Self-Esteem r/t deteriorating physiological condition, social isolation, and decreased  environmental control aeb pt's loss of independence

# data[].attributes.subject
Situational Low Self-Esteem r/t deteriorating physiological condition, social isolation, and decreased  environmental control aeb pt's loss of independence

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PRN Dilaudid

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Take weights at regular intervals (rationale: monitors effectiveness of dietary plan) (Unbound Medicine, 2022d)

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Anemia

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Thorough GI assessment, which includes bowel sounds (rationale: determines ability of digestive tract to handle the digestive process) (Unbound Medicine, 2022d)

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Swallow assessment completed. Candidate for TPN. Might receive PICC on Feb. 17th

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Monitor and assess inputs and outputs (Rationale: many factors related to this, such as diuresis, can alter electrolytes) (Unbound Medicine, 2022c)

# data[].attributes.body
Monitor heart rate and rhythm by palpitation and auscultation (Rationale: bradycardia, tachycardia, and other dysrhythmias are associated with potassium, calcium, and magnesium imbalances) (Unbound Medicine, 2022c)

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Assess mental status, note client/caregiver report of change or altered LOC (rationale: most common sign of sodium imbalance and can be associated with additional electrolyte imbalances) (Unbound Medicine, 2022c)

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Maintain and encourage good skin hygiene (shower, thorough washing, apply lotion/skin protectant) (Rationale: reduces risk of dermal trauma and promotes pt comfort) (Unbound Medicine, 2022b)

# data[].attributes.body
Determine pt's discomfort level (e.g., mild or deep pain and severe itching) (Rationale: clarifies interventions and priorities needed) (Unbound Medicine, 2022b)

# data[].attributes.body
Thorough skin assessment (type of skin distribution and general skin health) (Rationale: creates baseline to ascertain whether breakdown is getting better or worse) (Unbound Medicine, 2022b)

# data[].attributes.body
Convey empathy by acknowledge and validate pain (Rationale: reduces defensiveness, promotes trust, and enhances cooperation with regimen) (Unbound Medicine, 2022a)

# data[].attributes.body
Ascertain pt's goal for pain (e.g., would they be satisfied with 1 pain) (Rationale: 0 pain might not be achievable for the pt but sufficient discomfort could be alleviated by bringing the pain down) (Unbound Medicine, 2022a)

# data[].attributes.body
https://nursing.unboundmedicine.com/nursingcentral/view/nurses-pocket-guide/2819083/all/acute_Pain?q=acute+pain

https://nursing.unboundmedicine.com/nursingcentral/view/nurses-pocket-guide/2819185/all/impaired_Skin_Integrity_and_risk_for_impaired_Skin_Integrity#4.0

https://nursing.unboundmedicine.com/nursingcentral/view/nurses-pocket-guide/2819200/all/imbalanced_Nutrition:_less_than_body_requirements#4.0

https://nursing.unboundmedicine.com/nursingcentral/view/nurses-pocket-guide/2819242/all/situational_low_Self_Esteem_and_risk_for_situational_low_Self_Esteem#3.0

# data[].attributes.body
Evaluate pain characteristics and intensity (1-10, PQRST) (Rationale: creates baseline to evaluate whether pain is becoming worse, staying the same, or getting better) (Unbound Medicine, 2022a)

# data[].attributes.body
Note location and quality (REEDA) of surgical incision (Rationale: shape of incision can influence degree of postoperative pain experienced.)

# data[].attributes.headline
Risk for Electrolyte Imbalance r/t partial gastrectomy aeb excess bowel incontinence 

# data[].attributes.subject
Risk for Electrolyte Imbalance r/t partial gastrectomy aeb excess bowel incontinence 

# data[].attributes.headline
Acute Pain r/t Bowel Perforation aeb 5/10 generalized pain throughout the abdomen 

# data[].attributes.subject
Acute Pain r/t Bowel Perforation aeb 5/10 generalized pain throughout the abdomen 

# data[].attributes.headline
Risk for Imbalanced Nutrition: Less than Body Requirements 

# data[].attributes.subject
Risk for Imbalanced Nutrition: Less than Body Requirements 

# data[].attributes.headline
Impaired Skin Integrity r/t immobility and frequently loose stools aeb discomfort and redness in perineal area 

# data[].attributes.subject
Impaired Skin Integrity r/t immobility and frequently loose stools aeb discomfort and redness in perineal area 

# data[].attributes.body
Perforated viscous/stomach