NURSING CARE PLAN CUES Objectives: 20% or more under ideal body weight weakness of muscles required for

swallowing or mastication poor muscle tone NURSING DIAGNOSIS Imbalanced nutrition: less than body requirements related to inability to ingest adequate nutrients Analysis Is the intake of nutrients insufficient to meet metabolic needs. Nutrition is the sum of all the interactions between an organism and the food it consumes. Nutrients have three major functions: providing energy for body processes and movement, providing structural material for body tissues, and GOALS & OBJECTIVES Goal: After 2 days of nursing intervention, the client will have an adequate nutrition through oral intake. Objectives: After 1 day of nursing intervention, the client will increase her weight within 10% of ideal body weight Obtain and record patients weight at same time every day Keep strict documentation of intake, output, and calorie count. To obtain most accurate readings INTERVENTIONS RATIONALE EVALUATION

This information is necessary to make an accurate nutritional assessment and maintain client safety. Patients perception of actual intake may differ.

Obtain nutritional history; include family, significant

regulating processes. (Fundamen tals of Nursing, 8th Edition, Volume II p.1232)

others, or caregiver in assessment. Determine etiological factors for reduced nutritional intake. After 8 hours of nursing intervention, the client will have an increase amount or type of nutrients ingested. Proper assessment guides intervention. For example, patients with dentition problems require referral to a dentist. Many psychological, psychosocial, and cultural factors determine the type, amount, and appropriateness of food consumed. Distraction can help direct attention away form from the sensation of nausea.

Monitor or explore attitudes toward eating and food.

Provide distraction from the sensation of nausea, using soft music, television, and videos per the client preference. Determine clients likes and

dislikes, and collaborate with dietitian to provide favorite foods. Ensure that client receives small, frequent feedings, including a bedtime snack, rather than three larger meals. Explain the importance of adequate nutrition and fluid intake.

Client is more likely to eat foods that he or she particularly enjoys. Large amounts of food may be objectionable, or even intolerable, to the client. Client may have inadequate or inaccurate knowledge regarding the contribution of good nutrition to overall wellness.