Nursing Diagnosis: Nutrition: imbalanced, less than body requirements r/t unwillingness to eat Cause Analysis: Adequate nutrition is necessary
to meet the body’s demands. Nutritional status can be affected by disease or injury states; physical factors, social factors or psychological factors. (Gulanick/Myers (2007) Nursing Care Plans 6th ed., pp. 134-135) When you are physically hungry, every cell in your body sends out signals requesting nutrients. Your cells do not have cravings for specific foods. They want water, vitamins, minerals, amino acids (proteins), fatty acids, and glucose, which can be provided from a variety of vegetables, fruits, grains, legumes, meats, and calcium-rich foods. (Wilson, B. (2001) Reasons We Eat: Healthful and Harmful. http://www.balancedweightmanagement.com/Reasons%20to%20Eat.htm retrieved October 5, 2009) Assessment NOC with SMART NIC with interventions Rationale Evaluation objectives SUBJECTIVE: Nutrition Management Nutritional Status: Food and Fluid > Patient reported of Intake change of weight STO: approximately from 64 > After two hours and of Independent MET AEB eating half of kilograms to 55 nursing interventions, the his meal during kilograms patient will be able to eat breakfast half of his meal. * Document actual weight; do not Patients may be unaware of their actual estimate. weight or weight loss due to estimating LTO weight. OBJECTIVE > After the 7 hr shift, the Gulanick/Myers. (2007). Nursing Care NOT MET AEB refusal >inability to procure patient will be able to Plans 6th ed., pp.135-137 to record adequate amounts of record his food intake food within his 2 meals. >unwillingness to eat * Obtain nutritional history; include Patient’s perception of actual intake may >(9-4-09) family, significant others, or caregiver differ. Hematocrit = 38.0 % in assessment. Gulanick/Myers. (2007). Nursing Care (decreased) Plans 6th ed., pp.135-137 * Determine etiological factors for Proper assessment guides intervention. reduced nutritional intake. For example, patients with dentition problems require referral to a dentist, whereas patients with memory losses may require services such as Meals-on-Wheels. Gulanick/Myers. (2007). Nursing Care
Plans 6th ed., pp.135-137 * Monitor or explore attitudes toward Many psychological, psychosocial, and eating and food. cultural factors determine the type, amount, and appropriateness of food consumed. Gulanick/Myers. (2007). Nursing Care Plans 6th ed., pp.135-137 * Monitor environment in which eating occurs. Fewer families today have a general meal together. Many adults find themselves "eating on the run" (e.g., at their desk, in the car) or relying heavily on fast foods with reduced nutritional components. Gulanick/Myers. (2007). Nursing Care Plans 6th ed., pp.135-137 * Encourage patient participation in recording food intake using a daily Determination of type, amount, and log. pattern of food or fluid intake is facilitated by accurate documentation by patient or caregiver as the intake occurs; memory is insufficient. Gulanick/Myers. (2007). Nursing Care Plans 6th ed., pp.135-137 * Weigh patient weekly. During aggressive nutritional support, patient can gain up to 0.5 pound/day. Gulanick/Myers. (2007). Nursing Care Plans 6th ed., pp.135-137
* Establish appropriate short- and Depending on the etiological factors of long-range goals. the problem, improvement in nutritional status may take a long time. Without realistic short-term goals to provide tangible rewards, patients may lose interest in addressing this problem. Gulanick/Myers. (2007). Nursing Care Plans 6th ed., pp.135-137 * Suggest ways to assist patient ith meals as needed. Ensure a pleasant environment, facilitate proper position, and provide good oral hygiene and dentition. Elevating the head of bed 30 degrees aids in swallowing and reduces risk of aspiration. Gulanick/Myers. (2007). Nursing Care Plans 6th ed., pp.135-137 Collaborative * Monitor laboratory values that indicate nutritional wellbeing/deterioration: o Serum albumin This indicates degree of protein depletion (2.5 g/dl indicates severe depletion; 3.8 to 4.5 g/dl is normal). Gulanick/Myers. (2007). Nursing Care Plans 6th ed., pp.135-137 This is important for iron transfer and typically decreases as serum protein decreases.
Gulanick/Myers. (2007). Nursing Care Plans 6th ed., pp.135-137 o RBC and WBC counts These are usually decreased in malnutrition, indicating anemia and decreased resistance to infection. Gulanick/Myers. (2007). Nursing Care Plans 6th ed., pp.135-137 o Serum electrolyte values Potassium is typically increased and sodium is typically decreased in malnutrition. Gulanick/Myers. (2007). Nursing Care Plans 6th ed., pp.135-137 * Consult dietitian for further assessment and recommendations regarding food preferences and nutritional support. Dietitians have a greater understanding of the nutritional value of foods and may be helpful in assessing specific ethnic or cultural foods (e.g., "soul foods," Hispanic dishes, kosher foods). Gulanick/Myers. (2007). Nursing Care Plans 6th ed., pp.135-137