Assessment Diagnosis Inference Planning Interventions Rationale Evaluation

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

 Monitor or explore Many psychological,

attitudes toward psychosocial, and
 eating and food. cultural factors
determine the type,
amount, and
appropriateness of
food consumed.

 Encourage patient
participation in Determination of type,
recording food amount, and pattern
intake using a daily of food or fluid intake
log. as facilitated by
accurate
documentation by
patient or caregiver as
the intake occurs;
memory is insufficient.

 Monitor patient During aggressive

daily or weekly nutritional support,
patient can gain up to
0.5 lbs per day.

 Provide
companionship Attention to the social
during mealtime. aspects of eating is
important in both the
hospital and home
setting.
 Build up and Pleasing milieu helps
persuade a in lowering stress and
pleasing milieu for is more favorable to
meals. Dish up eating. It also
foods in well- encourages
ventilated, socialization and
pleasing maximizes patient
environment, with comfort when eating
unhurried difficulty cause
ambiance, friendly discomfiture.
company.

 Give frequent
Lowers discomfort
mouth care, noting
related with nausea or
secretion
vomiting, oral lesions,
precautions.
mucosal dryness, and
Prevent us of
halitosis. Clean mouth
alcohol-containing
may improve appetite
mouthwashes

Metabolism and
 Encourage
utilization of nutrients
exercise as
are enhanced by
indicated
activity.

Collaborative
Dietitians have a
 Ask dietitian for broader knowledge of
further evaluation the nutritional value of
and suggestions foods and may be
regarding food useful in evaluating
partialities and specific ethnic or
nutritional cultural foods.
assistance.