# 1 Imbalanced Nutrition: Less Than Body Requirements

Assessment Rationale
The first and vital step in an anthropomorphic assessment is to measure an individual’s weight accurately using a
scale. Weight is used as a basis for caloric and nutritional requirements. When a person loses weight unintentionally,
it can be an indicator of poor health and an inability of the body to fight off  infection. Also, when a person gains
weight, it can indicate poor nutritional practices or a side effect of a medication they might be taking (Padilla et al.,
2021). 
 In pregnant women, having low pre-pregnancy weight and inadequate weight gain can indicate growth
problems and potential low birth weight for babies.
1. Determine real, exact body
 For newborns, they are weighed with the use of balance scales or digital scales. Infants born weighing less
weight for age and height. Do not
than 5 pounds, 8 ounces (2,500 grams) are thought to have a low birth weight. An
estimate.
average newborn typically weighs about 8 pounds. Low-birth-weight infants may be healthy even though
they are small. But low-birth-weight infants can also have various serious health problems. Newborns are
weighed so frequently after birth because weight is an excellent indicator of nutritional health in infants.

2. Determine the patient’s height.
3. Determine the patient’s body
mass index (BMI).
An individual’s height is not commonly indicative of their health on its own. Nevertheless, when combined with
their weight, it can reveal a lot about their health in terms of how much they weigh, likened to how tall they are.
Thus, taller individuals will typically weigh more than shorter ones, so the proportions of the measurements have to
be considered (Padilla et al., 2021). A person’s height is measured using a measuring tape. 
BMI is determined by combining two anthropometric variables: weight in kilograms (kg) and height in square
meters (m2). A high BMI can indicate too much fat on the body, while a low BMI can indicate too little fat on the
body. The higher an individual’s BMI, the greater their chances of developing certain serious conditions, such as
heart disease, high blood pressure, and diabetes. A very low BMI can signify various health problems,
including anemia, decreased immune function, and bone loss  (Padilla et al., 2021).

Calculating for the BMI: 

BMI is calculated the same way for people of all ages. However, BMI is interpreted differently for adults and children.
The formula is BMI = kg/m2,where kg is a person’s weight in kilograms and m2 is their height in meters squared.
Body Mass Index for Adults
Adults aged 20 and older can interpret their BMI based on standard weight status categories. These are the same for men and
women of all ages and body types (CDC, 2000).

BMI Weight Status

Below 18.5 Underweight

18.5 – 24.9 Normal

25.0 – 29.9 Overweight

30.0 and above Obese

Body Mass Index for Children

BMI is interpreted differently for people under age 20. BMI is age- and sex-specific for children and teens and is often
considered BMI-for-age. A high amount of body fat in children can lead to weight-related diseases and other health issues. Being
underweight can also put one at risk for health issues (CDC, 2000).
Body mass index-for-age percentiles for boys 2 to 20 years
Body mass index-for-age percentiles for girls 2 to 20 years

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 Percentile Weight Status

Below 5th Underweight

5th –  85th NORMAL

85th – 95th  Overweight

95th and above Obese

Children’s anthropometric data reflect growth and development, general health status, and dietary adequacy over time.
In adults, body measurement data are used to assess and evaluate disease risk, body composition changes, and health and dietary
status over the adult lifespan (McDowell et al., 2008).

Other anthropometric measurements are head circumference, somatotype, and body circumferences to assess adiposity (waist,
hip, and limbs) and skinfold thickness. Typical equipment list required to obtain anthropometric measurements includes weight
scale, calibration weights, stadiometer, knee caliper, skinfold calipers, nonstretchable tape measure, and infantometer to measure
the recumbent length (Casadei & Kiel, 2020).

4. Assess the patient’s nutritional
risk using nutritional risk screening
tools.
Nutritional risk screening tools are very useful in the everyday routine to detect potential or manifest malnutrition in
a timely method. At least 33 different nutritional risk screening tools exist. Still, the three most common are the
Nutritional Risk Screening 2002 (NRS-2002) for the inpatient setting, the Malnutrition Universal Screening Tool
(MUST) for the ambulatory setting, and the Mini Nutritional Assessment (MNA) for institutionalized geriatric
patients (Reber et al., 2019).
 4.1. The Nutritional Risk Screening 2002 (NRS-2002). This is the most common nutritional risk
screening tool used in hospitals. It incorporates pre-screening with four questions. In case of a positive
outcome in one of the questions, a screening pursues, which has surrogate measures of nutritional status,
with static and dynamic parameters and data on the severity of the disease (stress metabolism).
 4.2. The Malnutrition Universal Screening Tool (MUST). This nutritional risk screening tool was
designed to determine malnourished individuals in all care settings (hospitals, nursing homes, home care,
etc.). It was the basis for the NRS-2002.
 4.3. The Mini Nutritional Assessment Short-Form (MNA). This nutritional risk screening tool is most
often used in standardized geriatric patients by incorporating screening and assessment features. Unlike
the NRS-2002, the MNA comprises different components (altered sense of taste and smell, loss of
appetite, loss of thirst, frailty, depression) usually suitable for the nutritional status of older people.

5. Assess the patient’s nutritional
status.
Assessment of the nutritional status should be conducted in patients identified as at nutritional risk following the
screening for risk of malnutrition. Assessment allows the nurses and health care providers to collect more
information and perform a nutrition-focused physical examination to distinguish if there is a nutrition issue, identify
the problem, and determine the severity (Reber et al., 2019).
 5.1. The Subjective Global Assessment (SGA). This is the most common tool used in assessing the
nutritional status. It contains data on medical history (dietary intake change, weight loss, gastrointestinal
and functional impairment) and physical examination (muscle wasting, loss of subcutaneous fat, ascites,
ankle edema, and sacral edema). Each patient is classified as: well-nourished (SGA-A), moderately or
suspected of being malnourished (SGA-B), or severely malnourished (SGA-C). 

6. Assess the patient’s eating A thorough understanding of the patient’s eating pattern will provide the health care team baseline data, understand
pattern. what interventions might be helpful, and aid in determining nutritional risk and worsening nutritional status. A study
revealed that girls and women with type 1 diabetes have increased rates of disturbed eating behaviors and clinically
significant eating disorders than their nondiabetic counterparts (Goebel-Fabbri, 2009).

7. Assess the patient’s food choices Aside from physical assessment, a comprehensive understanding of the patient’s nutritional history is necessary to

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by taking a nutritional history with
the participation of significant
others.
8. Compare usual food intake to
USDA Food Pyramid, noting
slighted or omitted food groups.
9. Ascertain etiological factors for
decreased nutritional intake.
10. Look for physical signs of poor
nutritional intake.
determine the degree of malnutrition accurately, if present, and metabolic energy needs. It is necessary to assess
their usual daily food intake before improving patients’ dietary habits or offering them nutritional guidance. Also,
taking a nutrition history will heighten patients’ awareness of nutritional health (Hark & Deen, 1999).  The nurse can
ask questions like: 
 How many meals and snacks do you eat in 24 hours?
A good way to begin is to ask patients what they consume during the day and night to assess their overall
intake. This information will also reveal irregular eating habits.
 How often do you eat high-fiber foods such as cereals, fruits, and vegetables?
According to the American Cancer Society, at least five servings of fruits and vegetables and at least one
serving of a fiber-rich cereal every day.  Unfortunately, the National Health and Nutrition Examination
Survey (NHANES) revealed only 23 percent of Americans eat five or more servings of fruits and
vegetables every day.
 How often do you usually consume dairy products, and what type?
Because of calcium‘s pivotal role in the normal development of healthy bones, NHANES III data revealed
that most Americans do not consume adequate calcium and that older adults and teenagers have the
greatest risk for a low calcium intake.
 What types of food and beverages do you usually consume in a day?
Does the patient eat poultry products, fish, desserts, sweets, or consumes enough water in a day? Aside
from food, a lack of fluid intake plays a fundamental role in a patient’s nutritional status.
The nurse plays an integral role in collecting these data. Although there is no single test to determine malnutrition,
the utilization of a complete nutritional assessment is the most useful tool to identify and treat malnutrition properly.
Family members may provide more accurate details on the patient’s eating habits, especially if the patient has
altered perception.
The United States Department of Agriculture (USDA) created the food pyramid in 1992. It was called the “Food
Guide Pyramid” or “Eating Right Pyramid.” It was updated in 2005 to “MyPyramid.” The new food pyramid was
eventually replaced in 2011 by the USDA’s “MyPlate.” This colorful plate is divided into four sections — one for
fruit, veggies, protein, and grains, and has a circle for dairy in the corner. In a study, MyPlate guidelines have been
available to the public since it was updated, and findings of this study show that the guidelines influenced the food
choices of at least 40% of the participants. It could be inferred that public awareness and use of MyPlate guidelines
will grow over time (Uruakpa et al., 2013).
Several factors may affect the patient’s nutritional intake, so it is vital to assess properly. Ambulatory patients with
nutritional problems such as weight loss may be experiencing difficulties unrelated to disease. Patients with
dentition problems need a referral to a dentist. It may also be related to mastication or swallowing food, or there may
be underlying depression or a lack of social interaction. At the same time, patients with memory losses may need
services like Meals on Wheels. Other medications also affect the appetite of the patient. All these factors can reduce
voluntary intake, are remediable, and should be considered in patients suspected of having nutritional problems.
Based on a study, patients with heart failure most often rated as affecting food intake were anxiety, fatigue, sadness,
shortness of breath, nausea, decreased hunger sensations, and diet restrictions. Healthy elders rated factors most
often as affecting food intake were eating alone, reduced hunger sensations, early satiety, and decreased senses of
taste and smell. Among patients with heart failure, many factors distinctive from those present due to age were
reported to affect food intake (Lennie et al., 2006). 
The patient encountering nutritional deficiencies may resemble to be sluggish and fatigued. Other manifestations
include decreased attention span, confused, pale and dry skin, subcutaneous tissue loss, dull and brittle hair, and red,
swollen tongue and mucous membranes. Vital signs may show tachycardia and elevated BP. Paresthesias may also
be present. Other signs that may indicate poor nutrition include: 
 Iron Deficiency. If patients’ iron levels are low, they may frequently experience headaches, dizziness, and
chills. If they have a thyroid disorder, it can make their muscles weak. Painful joints and paleness, and
dryness of skin may also be present. Too little iron can also cause hair to fall out or stop growing.
 Vitamin A Deficiency. If a person doesn’t take in enough vitamin A, night vision and the sharpness of
sight could deteriorate over time.
 Vitamin B1, B2, & B6 Deficiency. Dandruff, seborrheic dermatitis, mouthulcers such as canker sores,
and angular cheilitis may indicate deficiencies in thiamine (vitamin B1), riboflavin (vitamin B2), and
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11. Note the patient’s perspective
and feeling toward eating and food.
12. Evaluate the environment in
which eating happens.
13. Assess the patient’s ability to
obtain and use essential nutrients.
14. Review laboratory values that
indicate well-being or deterioration.
pyridoxine (vitamin B6).
 Vitamin B3 Deficiency. Niacin (vitamin B3) is necessary for keeping hair healthy. Alopecia, a condition
in which hair falls out in small patches, is one possible symptom of niacin deficiency.
 Vitamin B7 Deficiency. Biotin (vitamin B7) is another B vitamin that, when deficient, may be related to
hair loss.
 Folate Deficiency. Folate is the natural form of folic acid (vitamin B9) specifically necessary for women
of childbearing age. Symptoms of a folate deficiency include irritability, diarrhea, fatigue, poor growth,
and a smooth, tender-feeling tongue.
 Vitamin B12 Deficiency. Vitamin B12 deficiency can create burning sensations in the feet or tongue,
mild cognitive impairment, and changes in memory, thinking, or behavior. Over time, B12 deficiency can
permanently damage the nervous system, traveling up the spine and into the brain.
 Calcium Deficiency. Calcium deficiency could cause arrhythmia or irregular heartbeat and even lead to
chest pains. A person who might not be getting enough calcium is muscle cramps, tingling fingers, muscle
twitching, and fractures.
 Magnesium Deficiency. The primary symptoms of severe magnesiumdeficiency include migraines,
abnormal heart rhythm, restless leg syndrome, fatigue, and muscle cramps.
 Potassium Deficiency. Symptoms of a deficiency include abnormal heart rhythm or palpitations, tingling
and numbness, muscle weakness, muscle twitching, muscle cramps, constipation, and an a.
 Vitamin C Deficiency. When brushing and flossing, individuals with vitamin C deficiency experience
redness, swelling, and bleeding gums. Another sign might be that they bruise easily.
 Vitamin D Deficiency. If a patient feels weak and has pain in the bones, the individual might be deficient
in vitamin D.
 Zinc Deficiency. Zinc is necessary for protein synthesis and cell division, two processes needed for hair
growth. As such, zinc deficiency may cause hair loss.
Awareness of these history and physical examination elements can help physicians, dietitians, nurses, and
pharmacists to provide optimal care for these patients (Jensen & Binkley, 2002).
Various psychological, psychosocial, religious, and cultural factors determine the type, amount, and appropriateness
of food utilized. A study concerning anorexia nervosa, bulimia nervosa, binge eating disorder, and obesity without
eating disorders in female patients revealed that anorexia and bulimia nervosa patients presented more dysfunctional
eating attitudes, whereas obese and binge eating disorder patients presented interesting differences. Similarities and
differences support an individualized therapeutic approach for eating disorders and obese patients (Alvarenga et al.,
2014). For example, individuals with anorexia nervosa demonstrate a severe engagement in behaviors to reduce their
weight, which leads to severe underweight status (Keating et al., 2012).
Most adults find themselves “eating on the run” or relying massively on fast foods with lower nutritional
components. A study indicated that a high activity level causes people to prefer something instant. Fast food is
extremely easy to get and does not demand a long time to be served. Most fast foods are high in calories, cholesterol,
fat, and salt but low in fiber (Widyantara et al., 2014). Older people living independently may not have the drive to
prepare meals for themselves. Availability of services that can be supplemented by family or community, or
subscribing to a meal plan, might greatly influence their food intake. The need for a different environment would be
highlighted if the services were unavailable.
Several factors may affect the patient’s nutritional intake, so it is necessary to assess accurately. Cases of vitamin D
deficiency rickets have been reported among dark-skinned infants and toddlers who were exclusively breastfed and
were not given supplemental vitamin D (Ziegler et al., 2006).
Laboratory tests play a significant part in determining the patient’s nutritional status. An abnormal value in a single
diagnostic study may have many possible causes.
 14.1. Serum albumin. This determines the degree of protein reduction (2.5 g/dl signifies severe
diminution; 3.8 to 4.5 g/dl is normal).
 14.2. Transferrin. This is vital for iron transfer and typically decreases as serum protein decreases.
 14.3. RBC and WBC. These values frequently drop during malnutrition, indicating anemia, and reduced
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 14.4. Serum electrolyte values. Potassium is typically elevated, and sodium is typically lowered in
Nursing intervention
1. Ascertain healthy body weight for age and
height. Refer to a dietitian for a complete
nutrition assessment and methods for
nutritional support.
2. Set appropriate short-term and long-term
goals.
3. Provide a pleasant and quiet environment.
4. Promote proper positioning.
5. Provide good oral hygiene and dentition.
6. If the patient lacks strength, schedule rest
periods before meals and open packages and
cut up food for the patient.
7. Provide companionship during mealtime.
8. Consider seasoning for patients with
changes in their sense of taste, if not
contraindicated.
9. Consider six small nutrient-dense meals
instead of three larger meals daily to lessen
the feeling of fullness.
10. Link usual food intake to USDA Food
Pyramid, noting slighted or omitted food
groups.
11. For patients with physical impairments,
refer to an occupational therapist for
adaptive devices.
12. For patients with impaired swallowing,
coordinate with a speech therapist
for evaluation and instruction.
13. If the patient is a vegetarian, evaluate if
obtaining sufficient amounts of vitamin B12
and iron.
14. Determine the time of day when the
patient’s appetite is at its peak. Offer the
highest calorie meal at that time.
15. Encourage family members to bring food
from home to the hospital.
16. Offer high protein supplements based on
individual needs and capabilities.
resistance to infection. Having anemia lacks enough healthy red blood cells to carry adequate oxygen to
the body’s tissues which can make a person feel tired and weak. And when the WBC count is very low,
the health care team may need to take steps to avoid an infection.
malnutrition.
Rationales
Experts like a dietician can determine nitrogen balance as a measure of the patient’s nutritional status. A
negative nitrogen balance may mean protein malnutrition. The dietician can also determine the patient’s
daily requirements of specific nutrients to promote sufficient nutritional intake.
Patients may lose concern in addressing this dilemma without realistic short-term goals.
A pleasing atmosphere helps in decreasing stress and is more favorable for eating. A quiet and
nondistracting environment can help the patient focus on eating. 
Elevating the head of the bed 30 degrees aids in swallowing and reduces the risk for aspiration with eating.
Oral hygiene has a positive effect on appetite and the taste of food. Dentures need to be clean, fit
comfortably, and be in the patient’s mouth to encourage eating.
Nursing assistance with activities of daily living (ADLs) will conserve the patient’s energy for activities
the patient values. Patients who take longer than one hour to complete a meal may require assistance.
Attention to the social perspectives of eating is important in hospital and home settings.
Seasoning may improve the flavor of the foods and attract eating.
Eating small, frequent meals lessens the feeling of fullness and decreases the stimulus to vomit.
The Food Guide Pyramid emphasizes the importance of balanced eating. The omission of entire food
groups increases the risk of deficiencies.
An expert may provide special devices that can help patients feed themselves.
A speech therapist may provide adjustments to the thickness and consistency of foods to improve
nutritional intake.
Strict vegetarians may be at particular risk for vitamin B12 and iron deficiencies. Proper care should be
taken when implementing vegetarian diets for pregnant women, infants, children, and the elderly.
Patients with liver disease often have their largest appetite at breakfast time.
Patients with specific ethnic or religious preferences or restrictions may not consider foods from the
hospital.
Such supplements can increase calories and protein without conflict with voluntary food intake.
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17. Offer liquid energy supplements. Energy supplementation has been shown to produce weight gain and reduce falls in frail elderly living in
the community.
18. Discourage caffeinated or carbonated These beverages can spoil the patient’s appetite by decreasing hunger and can lead to early satiety. 
beverages.
19. Keep a high index of suspicion of Impaired immunity is a critical adjunct factor in malnutrition-associated infections in all age groups.
malnutrition as a causative factor in
infections.
20. Encourage exercise. Metabolism and utilization of nutrients are improved by activity. See Activity Intolerance nursing
diagnosis. 
21. Consider the possible need for enteral or Nutritional support may be recommended for patients who cannot maintain nutritional intake by the oral
parenteral nutritional support with the route. If the gastrointestinal tract is functioning well, enteral tube feedings are indicated. For those who
patient, family, and caregiver, as cannot tolerate enteral feedings, parenteral nutrition is recommended.
appropriate.
22. Validate the patient’s feelings regarding Validation lets the patient know that the nurse has heard and understands what was said, promoting
the impact of current lifestyle, finances, and the nurse-patient relationship.
transportation on the ability to obtain
nutritious food.
23. Once discharged, help the patient and Change is difficult. Multiple changes may be overwhelming.
family identify areas to change that will
make the greatest contribution to improved
nutrition.

24. Adapt modification to their current Accepting the patient’s or family’s preferences shows respect for their culture.
practices.

#2 Imbalanced Nutrition: More Than Body Requirements 

Goals and Outcomes

1. Patient claims ownership for current eating patterns.
2. Patient designs dietary modifications to meet individual long-term goal of weight control, using principles of variety,
balance, and moderation.
3. Patient verbalizes accurate information about benefits of weight loss.
4. Patient verbalizes measures necessary to attain beginning weight reduction.
5. Patient states related factors contributing to weight gain.
6. Patient identifies behaviors that remain under his or her control.
7. Patient fulfills desired weight loss in a reasonable period (1 to 2 pounds per week).
8. Patient organizes relevant activities requiring energy expenditure into daily life.
9. Patient uses sound scientific sources to evaluate need for nutritional supplements.
10. Patient demonstrates appropriate selection of meals or menu planning toward the goal of weight reduction.
Assessment Rationales

Exact weight needs to be documented, as patient may have been estimating over time. Men
with waist circumference greater than 40 inches and women with greater than 35 inches are at
higher risk for obesity-related complications. BMI describes relative weight for height and is
Note weight, waist circumference, and calculate body
significantly associated with total body fat content. BMI is the patient’s weight in kilograms
mass index (BMI).
divided by the square of his or her height in meters. A BMI between 20 and 24 is associated
with healthier outcomes. BMIs greater than 25 are associated with increased morbidity and
mortality.

Obtain a thorough history. The most appropriate patients for the nursing intervention of Weight Management are adults

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 Assessment Rationales

with no major health problems who require diet therapy.

Nondieting approaches focus on changing disturbed thoughts, emotions, and body

Evaluate patient’s physiological status in relation to
image associated with obesity to help obese persons accept themselves and resolve concerns
weight control.
that prevent long-term weight maintenance.

Medical complications include cardiovascular and respiratory dysfunction, sleep-disordered

Assess the effects or complications of being
breathing, higher incidence of diabetes mellitus, and aggravation of musculoskeletal
overweight.
disorders. Social complications and poor self-esteem may also result from obesity.

Know patient’s knowledge of a nutritious diet and This information is helpful in developing an individualized teaching plan based on patient’s
need for supplements. current state.

Assess dietary intake through 24-hour recall or

Data may not be fully accurate. Permits appraisal of patient’s knowledge about diet also.
questions regarding usual intake of food groups.

Determine the patient’s readiness to initiate a weight

loss regimen by asking questions such as the following:

 
More specific directions regarding weight loss can be addressed if the patient is in the
preparation or action stages.
How do you feel about starting a weight loss program?
Are you ready to choose a time to start changing your
eating habits?

Observe for situations that indicate a nutritional

Such observations help gain a clear picture of the patient’s dietary habits.
intake of more than body requirements.

Conduct a nutritional assessment to include:

 

 Daily food intake – type and

amount of food Environmental factors greatly contribute to obesity than genetics or biological vulnerability.
 Approximate caloric intake Assessment of current eating patterns provides a baseline for change. Assessment methods
 Activity at time of eating may include 24-hour recall and foods eaten, food diaries/records, or food frequency recording
 Feelings at time of eating using typical food groups.
 Location of meals
 Meals skipped
 Snacking patterns
 Social/familial considerations

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 Assessment Rationales

Discover the behavioral factors that contribute to Overeating may be triggered by environmental cues and behavioral factors unrelated to
overeating. physiological hunger sensations.

Determine patient’s motivation to lose weight, whether Successful change is more likely to occur if patient has formulated plans for dealing with any
for appearance or health benefits. barriers.

Food labels contain information necessary in making appropriate selections, but can be
misleading. Patients need to understand that “low-fat” or “fat-free” does not mean that a food
Assess the patient’s ability to read food labels.
item is calorie free. In addition, attention should be paid to serving size and the number of
servings in the food item.

Clinicians should be aware that apparently harmless herbal remedies may have potent
Assess for use of nonprescription diet aids. ingredients that are not subjected to the same analysis that the FDA devotes to prescription
drugs.

Determine the patient’s ability to plan a menu and This information provides the starting point for the educational sessions. Teaching content the
make appropriate food selections. patient already knows wastes valuable time and hinders critical learning.

Evaluate the patient’s ability to accurately identify

Serving sizes must be understood to limit intake according to a planned diet.
appropriate food portions.

Interventions Rationales

Patient contracts render a unique chance for patients to learn to analyze their behavior in
Initiate a patient contract that includes rewarding and
relationship to the environment and to choose behavioral strategies that will facilitate
reinforcing progressive goal attainment.
learning.

Improvement in nutritional status may take a long time. Patient may lose interest in the
Set appropriate short-term and long-term goals.
whole process without short-term goals.

Negotiate with the patient regarding the aspects of his

Give and take with the patient will lead to culturally harmonious care.
or her diet that will need to be modified.

Suggest patient to keep a diary of food intake and

Self-monitoring helps the patient assess adherence to self-determined performance criteria
circumstances surrounding its consumption (methods
and progress toward desired goals. Self-monitoring serves an important role in the
of preparation, duration of meal, social situation,
maintenance of internal standards of behavior.
overall mood, activities accompanying consumption).

Measuring food alerts patient to normal portion sizes. Estimating amounts can be extremely
Advise patient to measure food regularly.
inaccurate.

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Encourage water intake. Water helps in the elimination of byproducts of fat breakdown and helps prevent ketosis.

Review patient’s current exercise level. With patient

Exercise is vital for increased energy expenditure, for maintenance of lean body mass, and as
and primary healthcare provider, design a long-term
component of a total change in lifestyle.
exercise program.

It is important to most patients and their progress to have an actual reward that the scale
Weigh patient twice a week under the same conditions. shows. Monitoring twice a week keeps the patient on the program by not allowing him or
her to eat out of control for a couple of days and then fast to lose weight.

Permanent lifestyle changes must occur for weight loss to be long lasting. Excluding all
Educate patient about adequate nutritional intake. A
treats is not sustainable. During energy restriction, a patient should consume 72 to 80 g of
total plan permits occasional treats.
high biological value protein per day to lessen risk of ventricular arrhythmias.

Familiarize patient with the following behavior Self-monitoring is the centerpiece of behavioral weight loss intervention programs. In short,
modification techniques: self-monitoring is fundamentally linked to successful weight loss.

Self-monitor  

 Keep a food and exercise diary

 Graph weight weekly Stimulus control
 Limit food intake to one site in the
home
 Sit down at the table to eat
 Plan food intake for each day
 Rearrange schedule to avoid
inappropriate eating
 Save or reschedule everyday activities
for times when you are hungry
 Avoid boredom; keep a list of activities
on the refrigerator
 At a party: eat before you go, sit away
from the snack foods, and substitute
lower calorie beverages for alcoholic
ones
 Decide beforehand what to order in a
restaurant Slow down eating
 Drink a glass of water before each
meal; take sips of water between bites
of food
 Swallow food before putting more food
on the utensil
 Try to be the last one to finish eating
 Pause for a minute during your meal,
and attempt to increase the number of

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 pauses
 Reward yourself
 Chart your progress
 Make an agreement with yourself or
significant other for a meaningful
reward
 Do not reward yourself with food
 Cognitive strategies
 View exercise as a means of
controlling hunger
 Practice relaxation techniques
 Imagine yourself ordering a side salad,
diet dressing, low-fat milk, and a small
hamburger at a fast-food restaurant
 Visualize yourself enjoying a fresh
apple in preference to apple pie

Allow and encourage patient to adopt an exercise

Moderately intense physical activity for 30 to 45 minutes 5 to 7 days/week can expend the
routine that involves 45 minutes of exercise five times
1500 to 2000 calories/week that appear to be necessary to maintain weight loss.
per week.

Patients who are consuming excessive amounts of some nutrients may also be consuming
Observe for overuse of particular nutrients.
less than adequate amounts of others.

Provide the patient and family with information Because the goal is to obtain a permanent change in weight management, the decision
regarding the treatment plan options. regarding treatment plans should be left up to the patient and family.

Guide the patient regarding changes that will make a

Even modest weight loss contributes to diabetes and hypertension control.
major impact on health.

Acquaint the patient and family of the disadvantages of With a reduced-calorie diet alone, as much as 25% of the weight lost can be lean body mass
trying to lose weight by dieting alone. rather than fat.

Explain the importance of exercise in a weight control A physically conditioned person uses more fat for energy at rest and with exercise than a
program. sedentary person does.

Teach stress reduction methods as alternatives to

The patient needs to substitute healthy for unhealthy behaviors.
eating.

# 3 Deficient Knowledge
May be related to
 Lack of/misinterpretation of information
 Lack of interest in learning, lack of recall
 Inaccurate/incomplete information presented
Possibly evidenced by
 Statements of lack of/request for information about obesity and nutritional requirements
 Verbalization of problem with weight reduction
 Inadequate follow-through with previous diet and exercise instructions
Desired Outcomes
1. The client will verbalize understanding of the need for lifestyle changes to maintain/control weight.
2. The client will establish an individual goal and plan for attaining that goal.
3. The client will begin to look for information about nutrition and ways to control weight.
.
Assessment Rationale

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1. Determine the level of nutritional
knowledge and what the client
believes is the most urgent need.
2. Identify individual holistic long-
term goals for health (lowering blood
pressure, controlling serum lipid and
glucose levels).
It is necessary to know what additional information to provide. When the client’s views are listened to, trust is
enhanced. Micronutrient deficiencies observed in individuals with obesity could be a function of poor diet,
with decreased intake of vitamins and minerals (Astrup & Bügel, 2019).
A high relapse rate at a 5-year follow-up suggests obesity cannot be reliably reversed and cured. Shifting the
focus from initial weight loss and percentage of body fat to overall wellness may enhance rehabilitation. Diet-
induced weight loss can result in elevated levels of hormones that increase appetite. After successful weight
loss, circulating levels of these hormones do not decrease to levels recorded before diet-induced weight loss.
Therefore, long-term strategies are needed to prevent obesity relapse (Hamdy & Khardori, 2023)

Nursing intervention Rationale

1. Provide information about ways to
maintain satisfactory food intake in
settings away from home.
2. Identify other sources of
information like books, tapes,
community classes, and groups.
3. Emphasize the necessity of
continued follow-up care and
counseling, especially when plateaus
occur.
4. Identify alternatives to chosen
activity programs to accommodate
weather, travel, and so on.
5. Discuss the necessity of good skin
care, especially during the summer
months and following exercise.
“Smart” eating when dining out or when traveling helps the individual manage weight while still enjoying
social outlets. Balanced, low-calorie diets and reduced-portion size diets are the types that dietitians and other
weight-management professionals most commonly prescribe. Although none of these diets are useful for
short-term weight loss, none of them alone is associated with reliable, sustained weight loss (Hamdy &
Khardori, 2023)
Using different avenues of accessing information furthers client learning. Involvement with others who are
also losing weight can provide support. Online networks most frequently feature informational and emotional
support. Informational support pertains to the exchange of relevant information and advice, while emotional
support is the provision of caring and sympathy. Content analysis revealed that both forms of social support
are highly relevant in online support groups, with different health topics focusing on different forms
(Reifegerste et al., 2017).
As weight is lost, changes in metabolism occur, interfering with further loss by creating a plateau as the body
activates a survival mechanism, attempting to prevent “starvation.” This requires new strategies and aggressive
support to continue weight loss. As with the management of other chronic medical conditions, long-term
success in the management of obesity is contingent on long-standing follow-up with the weight-loss program.
Client visits may not need to occur as frequently during follow-up as during the initial weight loss phase.
However, they are paramount if the lessons learned regarding diet, exercise habits, and behavioral patterns are
to be maintained (Hamdy & Khardori, 2023).
This promotes the continuation of the program. Since approximately 27% of diet-induced weight loss is from
loss of muscle, the addition of exercise to caloric restriction is important. Studies have shown that muscle mass
loss is reduced to approximately 13% of the total weight loss when diet and exercise are combined (Hamdy &
Khardori, 2023).
This prevents skin breakdown in moist skin folds. To control moisture, advise the client to avoid tight
clothing, use pH-balanced liquid soap, cleansers, or disposable wipes; pat skinfolds dry, rather than
aggressively rubbing. Hair dryers st on cold also can be used to dry skin folds. Daily inspection of the skin,
routine cleansing, and moisturizing as needed by caregivers and clients are beneficial (Earlam & Woods,
2020).

#4 Impaired swallowing (Dsyphagia)

Assessment Rationales

Assess ability to swallow by positioning examiner’s thumb and index

finger on patient’s laryngeal protuberance. Ask patient to swallow;
The lungs are usually protected against aspiration by reflexes as cough or
feel larynx elevate. Ask patient to cough; test for a gag reflex on both
gag. When reflexes are depressed, the patient is at increased risk for
sides of posterior pharyngeal wall (lingual surface) with a tongue
aspiration.
blade. Do not rely on presence of gag reflex to determine when to
feed.

Cranial nerves VII, IX, X, and XII control motor function in the mouth and
pharynx. Coordinated function of muscles innervated by these nerves is
Evaluate the strength of facial muscles.
necessary to move a bolus of food from the mouth to the posterior pharynx
for controlled swallowing.

Check for coughing or choking during eating and drinking. These signs indicate aspiration.

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 Assessment Rationales

Observe for signs associated with swallowing problems (e.g.,

coughing, choking, spitting of food, drooling, difficulty handling oral
secretions, double swallowing or major delay in swallowing,
watering eyes, nasal discharge, wet or gurgly voice, decreased ability These are all signs of swallowing impairment.
to move tongue and lips, decreased mastication of food, decreased
ability to move food to the back of the pharynx, slow or scanning
speech).

Assess ability to swallow a small amount of water. If aspirated, little or no harm to the patient occurs.

Check for residual food in mouth after eating. Pocketed food may be easily aspirated at a later time.

Regurgitation indicated decreased ability to swallow food or fluids and an

Check for food or fluid regurgitation through the nares.
increased risk for aspiration.

A video-fluoroscopic swallowing study may be indicated to determine the

Evaluate the results of swallowing studies as ordered. nature and extent of any oropharyngeal swallowing abnormality, which aids
in designing interventions.

Determine patient’s readiness to eat. Patient needs to be alert, able If one of these factors is missing, it may be desirable to withhold
to follow instructions, hold head erect, and able to move tongue in oral feeding and do enteral feeding for nourishment. Cognitive deficits can
mouth. result in aspiration even if able to swallow adequately.

Nursing Interventions Rationales

For hospitalized or home care patients:

Before mealtime, provide for adequate rest periods. Fatigue can further add to swallowing impairment.

Eliminate any environmental stimuli (e.g., TV, radio) The patient can more concentrate when external stimuli are removed.

Provide oral care before feeding. Clean and insert dentures before
Optimal oral care promotes appetite and eating.
each meal.

If patient has impaired swallowing, consult a speech pathologist for Speech pathologists specialize in impaired swallowing. Early referral of
bedside evaluation as soon as possible. Ensure that patient is seen by CVA patients to a speech pathologist, along with early initiation of
a speech pathologist within 72 hours after admission if patient has nutritional support, results in decreased length of hospital stay, shortened
had a CVA. recovery time, and reduced overall health costs.

For impaired swallowing, use a dysphagia team composed of a

The dysphagia team can help the patient learn to swallow safely and
rehabilitation nurse, speech pathologist, dietitian, physician, and

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 Nursing Interventions Rationales

radiologist who work together. maintain a good nutritional status.

With impaired swallowing reflexes, secretions can rapidly accumulate in the

Place suction equipment at the bedside, and suction as needed.
posterior pharynx and upper trachea, increasing the risk of aspiration.

If patient has impaired swallowing, do not feed until an appropriate Feeding a patient who cannot sufficiently swallow results in aspiration and
diagnostic workup is completed. Ensure proper nutrition by possibly death. Enteral feedings via PEG tube are generally preferable
consulting with physician for enteral feedings, preferably a PEG to nasogastric tubefeedings because studies have shown that there is
tube in most cases. increased nutritional status and possibly improved survival rates.

If decreased salivation is a contributing factor:

 
Moistening and use of tart flavors stimulate salivation, lubricate food, and
improves the ability to swallow.
 Before feeding, provide the patient a lemon
wedge, pickle, or tart-flavored hard candy.
 Use artificial saliva.

If patient has an intact swallowing reflex, attempt to feed. Observe the

following feeding guidelines:

 Position patient upright at a 90-degree angle with This position allows the trachea to close and esophagus to open, which
the head flexed forward at a 45-degree angle. makes swallowing easier and reduces the risk of aspiration.

 Ensure patient is awake, alert, and able to follow As the patient becomes less alert the swallowing response decreases, which
sequenced directions before attempting to feed. increases the risk of aspiration.

 Begin by feeding patient one-third teaspoon of

applesauce. Provide sufficient time to masticate Gravy or sauce added to dry foods facilitates swallowing.
and swallow.

 Place food on unaffected side of tongue.  

 During feeding, give patient specific directions

(e.g., “Open your mouth, chew the food Proper instruction and focused concentration on specific steps reduce risks.
completely, and when you are ready, tuck your
chin to your chest and swallow”).

Maintain the patient in high-Fowler’sposition with the head flexed

Aspiration is less likely to happen in this position.
slightly forward during meals.

Instruct the patient not to talk while eating. Provide verbal cueing as
Concentration must be focus on the task.
needed.

Observe for uncoordinated chewing or swallowing; coughing shortly These are signs of impaired swallowing and possible aspiration.
after eating or delayed coughing, which may mean silent aspiration;

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 Nursing Interventions Rationales

pocketing of food; wet-sounding voice; sneezing when eating; delay

of more than 1 second in swallowing; or a variation in respiratory
patterns. If any of these signs are present, put on gloves, eliminate all
food from oral cavity, end feedings, and consult with a speech and
language pathologist and a dysphagia team.

Reassure the patient to chew completely, eat gently, and swallow

frequently, especially if extra saliva is produced. Give the patient
Such directions assist in keeping one’s focus on the task.
with direction or reinforcement until he or she has swallowed each
mouthful.

Classify food given to the patient before each spoonful if the patient Knowledge of the consistency of food to expect can prepare the patient for
is being fed. appropriate chewing and swallowing technique.

Advance slowly, giving small amounts; whenever possible, alternate

This technique helps prevent foods from being left in the mouth.
servings of liquids and solids.

Encourage high-calorie diet that involves all food groups, as

Dairy products can lead to thickened secretions.
appropriate. Avoid milk and milk products.

If patients pouch food to one side of their mouth, encourage them to Foods placed on the unaffected side of the mouth promote more complete
turn their head to the unaffected side and manipulate the tongue to chewing and movement of food to the back of the mouth, where it can be
the paralyzed side. swallowed. These strategies aid in cleaning out residual food.

If patient tolerates single-textured foods such as pudding, hot cereal,

or strained baby food, advance to a soft diet with guidance from the The dysphagia team should determine the appropriate diet for the patient on
dysphagia team. Avoid foods such as hamburgers, corn, and pastas the basis of progression in swallowing and ensuring that the patient is
that are difficult to chew. Also, avoid sticky foods such as peanut nourished and hydrated.
butter and white bread.

If the patient had a stroke, place food in the back of the mouth, on
the unaffected side, and gently massage the unaffected side of the Massage aids stimulate the act of swallowing.
throat.

Place whole or crushed pills in custard or gelatin. (First, ask a

pharmacist which pills should not be crushed.) Substitute Mixing some pills with foods helps reduce the risk for aspiration.
medication in an elixir form as indicated.

With self-feeding, the patient can establish the volume of a food bolus and
Encourage the patient to feed self as soon as possible.
the timing of each bite to promote effective swallowing.

If oral intake is not possible or in inadequate, initiate alternative

feedings (e.g., nasogastric feedings, gastrostomy feedings, or Optimal nutrition is a patient need.
hyperalimentation).

Use of straws can increase the risk of aspiration because straws can result in
For many adult patients, avoid using straws if recommended by
spilling of a bolus of fluid in the oral cavity as well as decrease control of
speech pathologist.
posterior transit of fluid to the pharynx.

Praise patient for successfully following directions and swallowing Praise reinforces behavior and sets up a positive atmosphere in which
appropriately. learning takes place.

Follow-up:

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 Nursing Interventions Rationales

Initiate a dietary consultation for calorie count and food Dietitians have a greater understanding of the nutritional value of foods and
preferences. may be helpful in guiding treatment.

More interventions:

An upright position guarantees that food stays in the stomach until it has
Keep patient in an upright position for 30 to 45 minutes after a meal.
emptied and decreases the chance of aspiration following meals.

Observe for signs of aspiration and pneumonia. Auscultate lung The presence of new crackles or wheezing, an elevated temperature or
sounds after feeding. Note new crackles or wheezing, and note white blood cell count, and a change in sputum could indicate aspiration of
elevated temperature. Notify physician as needed. food.

Discuss and demonstrate the following to the patient or caregiver:

 

 Avoidance of certain foods or fluids

 Upright position during eating
 Allowance of time to eat slowly and chew Both the patient and caregiver may need to be active participants in
thoroughly implementing the treatment plan to optimize safe nutritional intake.
 Provision of high-calorie meals
 Use of fluids to help facilitate passage of solid
foods
 Monitoring of the patient for weight loss
or dehydration

Weigh patient weekly. This is to help evaluate nutritional status.

Assess nutritional status regularly. If not adequately nourished,

work with dysphagia team to determine whether patient needs to Enteral feedings can maintain nutrition if patient is unable to swallow
avoid oral intake (NPO) with therapeutic feeding only or needs adequate amounts of food.
enteral feedings until patient can swallow adequately.

Discuss the importance of exercise to enhance the muscular strength Muscle strengthening can facilitate greater chewing ability and positioning
of the face and tongue to enhance swallowing. of food in the mouth.

Educate patient, family, and all caregivers about rationales for food It is common for family members to disregard necessary dietary restrictions
consistency and choices. and give patient inappropriate foods that predispose to aspiration.

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