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Student Nurses Community

NURSING CARE PLAN Imbalanced Nutrition (Less than body requirement)


ASSESSMENT

SUBJECTIVE:
Patient verbalizes
I always feel
weak and tired

OBJECTIVE:
Weight loss
Poor muscle tone

Vital signs:
t- 37 C
P- 59 bpm
Rr 17 br/min
BP 90/60 mmHg

DIAGNOSIS

INFERENCE

Imbalanced
Nutrition Less
than Body
Requirements
Related To
Inability to ingest
or digest food or
to absorb
nutrients because
of biologic,
psychologic, or
economic factors

Biologic,
psychologic,
economic
factors

Impair a
persons ability
to ingest or
digest food/
absorb nutrients

Imbalanced
Nutrition
(less than body
requirements)

PLANNING

After 2 weeks of
nursing
intervention, the
patient will be
able to:
Verbalize and
demonstrate
selection of
foods or meals
that will
achieve a
cessation of
weight loss.
Have weight
within 10% of
ideal body
weight.

INTERVENTION
S

Independent:
Document
actual weight
using
weighing
scale; do not
estimate

RATIONALE

Patients may be
unaware of their
actual weight or
weight loss due
to estimating
weight
Patient's
perception of
actual intake may
differ.

Obtain
nutritional
history;
include family, With proper
significant
assessment you
others, or
may be able to
caregiver in
plan appropriate
assessment.
interventions
(i.e., patients
Determine
with dentation
etiologic
problems may
factors for
require referral to
reduced
a dentist)
nutritional
intake
Many
psychological,
Monitor or

EVALUATION

After 2 weeks of
nursing
intervention, goal
met. Patient was
able to verbalize
understanding
and demonstrate
selection of meals
that help in
achieving
cessation of
weight loss; and
gained at least
10% of ideal body
weight.

Student Nurses Community

Electrolyte
imbalance

explore
attitudes
toward eating
and food.
Encourage
patient
participation
in recording
food intake
using a daily
log.
Monitor
patient daily
or weekly
Provide
companionshi
p during
mealtime.

psychosocial, and
cultural factors
determine the
type, amount,
and
appropriateness
of food
consumed.
Determination of
type, amount,
and pattern of
food or fluid
intake as
facilitated by
accurate
documentation
by patient or
caregiver as the
intake occurs;
memory is
insufficient.

Build up and
persuade a
During
pleasing
aggressive
milieu for
nutritional
meals. Dish
support, patient
up foods in
can gain up to
well0.5 lbs per day.
ventilated,
pleasing
Attention to the
environment,
social aspects of
with unhurried
eating is
ambiance,

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friendly
company.

Give
frequent
mouth care,
noting
secretion
precautions.
Prevent us of
alcoholcontaining
mouthwashes

Encourage
exercise as
indicated
Collaborative

important in both
the hospital and
home setting.
Pleasing milieu
helps in lowering
stress and is
more favorable to
eating. It also
encourages
socialization and
maximizes
patient comfort
when eating
difficulty cause
discomfiture.

Lowers
discomfort
Ask dietician
related with
for further
nausea or
evaluation
vomiting, oral
and
lesions, mucosal
suggestions
dryness, and
regarding food
halitosis. Clean
partialities
mouth may
and nutritional
improve appetite
assistance.
Metabolism and
utilization of
nutrients are
enhanced by
activity.

Student Nurses Community

Dieticians have a
broader
knowledge of the
nutritional value
of foods and may
be useful in
evaluating
specific ethnic or
cultural foods.