Student Nurses’ Community

NURSING CARE PLAN ─ Imbalanced Nutrition (Less than body requirement)

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
S

SUBJECTIVE: Imbalanced Biologic, After 2 weeks of Independent:  Patients may be After 2 weeks of
Nutrition Less psychologic, nursing unaware of their nursing
Patient verbalizes economic  Document
than Body intervention, the actual weight or intervention, goal
“I always feel factors actual weight
Requirements patient will be weight loss due met. Patient was
weak and tired” ↓ using
Related To able to: to estimating able to verbalize
Inability to ingest Impair a weighing understanding
weight
person’s ability  Verbalize and scale; do not
or digest food or and demonstrate
to ingest or demonstrate estimate  Patient's
to absorb selection of meals
digest food/ selection of perception of
OBJECTIVE: nutrients because  Obtain that help in
absorb nutrients foods or meals actual intake may
of biologic, ↓ nutritional achieving
Weight loss psychologic, or that will differ. cessation of
Imbalanced achieve a history;
economic factors Nutrition include family,  With proper weight loss; and
Poor muscle tone cessation of
(less than body significant assessment you gained at least
weight loss. 10% of ideal body
requirements) others, or may be able to
 Have weight caregiver in plan appropriate weight.
Vital signs:
within 10% of assessment. interventions
t- 37 C ideal body (i.e., patients
 Determine
weight. with dentation
P- 59 bpm etiologic
problems may
factors for
Rr – 17 br/min require referral to
reduced
a dentist)
BP 90/60 mmHg nutritional
intake  Many
psychological,
 Monitor or
 Student Nurses’ Community

Electrolyte explore psychosocial, and

imbalance attitudes cultural factors
toward eating determine the
and food. type, amount,
and
 Encourage
appropriateness
patient of food
participation consumed.
in recording
food intake  Determination of
using a daily type, amount,
log. and pattern of
food or fluid
 Monitor
intake as
patient daily facilitated by
or weekly accurate
 Provide documentation
companionshi by patient or
p during caregiver as the
mealtime. intake occurs;
memory is
 Build up and insufficient.
persuade a
pleasing  During
milieu for aggressive
meals. Dish nutritional
up foods in support, patient
well- can gain up to
ventilated, 0.5 lbs per day.
pleasing  Attention to the
environment, social aspects of
with unhurried eating is
ambiance,
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friendly important in both

company. the hospital and
home setting.
 Give
frequent  Pleasing milieu
mouth care, helps in lowering
noting stress and is
secretion more favorable to
precautions. eating. It also
Prevent us of encourages
alcohol- socialization and
containing maximizes
mouthwashes patient comfort
when eating
 Encourage
difficulty cause
exercise as discomfiture.
indicated
Collaborative  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.
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 Dieticians have a
broader
knowledge of the
nutritional value
of foods and may
be useful in
evaluating
specific ethnic or
cultural foods.