Nursing Care Plan

Scenario
Albert is a 54-year-old married man who has dropped by the clinic’s yearly health fair to find out about weight loss
planning. His only daughter is getting married in 8 months, and his wife has been asking him about losing some weight
before the big event. He works as a laborer at a meat packing plant and has health insurance. He states that he is
entitled to one checkup a year, but he has not taken advantage of that for several years because he is in good health and
does not want “to raise the cost of health care” any more than necessary. He says he is 5’10” tall and weighs about 220
pounds, “give or take a couple”. His weight has been stable in recent years, but he admits he rarely steps on a scale and
acknowledges that he might be “a bit overweight.” He says he needs to eat “a lot” to keep up his energy for work and
because he simply likes to eat almost anything. Activities outside work hours include only sedentary pastimes such as
watching television or playing cards. He asks for diet plan so he can lose about 40 pounds before the wedding.

Assessment Diagnosis Planning Implementation Evaluation

Subjective: Imbalanced Nutrition: Short Term Goals: 1. Establish rapport with At the end of the
More than body After 1 hour of nursing the patient. nursing interventions,
Patient acknowledges requirements related intervention, the patient 2. Discuss to the patient the outcome is met.
that he might be to excess intake and will be able to: the importance of Albert was able to
overweight, he says decreased activity - understand the maintaining a healthy understand the
that he needs to eat “a expenditure (as importance of proper diet and lifestyle importance of proper
lot” in order to keep up evidenced by weight diet and physical (inclusive of proper diet diet. He was able to
his energy for his work, of 220 lbs., activity. and physical activity). alter his lifestyle by
he simply eats almost undesirable eating - enumerate the 3. Discuss causes of selecting the meals he
anything. Patient patterns, and lack of foods/meals to be obesity and its effect to wants to eat and are
states he spends physical fitness on included in his diet. the body and health. also good sources of
sedentary pastimes pastimes). 4. Encourage patient to proper nutrients, and
suck as watching TV carry out and review by introducing proper
and/or playing cards as Severe obesity is Long Term Goal: daily food diary (caloric physical activities in his
his activities outside associated with a After 1 day of nursing intake, types and pastimes. Albert was
work. Patient wants to failure to maintain a intervention, the patient amounts of food, able to lose weight and
lose about 40 pounds diet or lifestyle will be able to: eating habits). reach his goal weight
in 8 months. change. The usual - demonstrate selection 5. Formulate an eating which is 180 lbs. within
amount of physical of meals and physical plan with the patient, 8 months.
Objective: activities that will help using patient’s height,
Age: 54 activity per day is
achieve weight loss body build, age,
Height: 5’10 lower than what is and will display gender, and individual
Weight: 220 lbs. advised for both improved energy level. patterns of eating,
BMI: 31.48 = Obese gender and age. energy, and nutrient
After 1 month of nursing requirements.
NANDA interventions, the patient 6. Emphasize to the
International nursing will be able to patient the importance
diagnosis (2015- demonstrate adequate of avoiding fad diets.
2017) weight loss 7. Discuss binge eating
and develop strategies
for dealing with these
episodes (substituting
other actions for
eating).
8. Identify realistic
increment goals for
weekly weight loss.
9. Consult with dietitian to
determine caloric and
nutrient requirements
for individuals weight
loss.