Assessment

Diagnosis

Inference

Planning

Interventions

Subjective:

Imbalanced
Nutrition Less
than Body
Requirements
Related To
Inability to ingest
or digest food or
to absorb
nutrients because
of biologic,
psychologic, or
economic factors

Biologic,
psychologic,
economic factors

After 2 weeks of
nursing
intervention, the
patient will be
able to:

Independent:

Patient verbalizes
I always feel
weak and tired

Objectives:
Weight loss
Poor muscle tone

Vital signs:
t- 37 C
P- 59 bpm
Rr 17 br/min
BP 90/60 mmHg

Electrolyte
imbalance

Impair a persons
ability to ingest or
digest food/
absorb nutrients

Imbalanced
Nutrition
(less than body
requirements)

verbalize and
demonstrate
selection of
foods or meals
that will
achieve a
cessation of
weight loss.
Have weight
within 10% of
ideal body
weight.

Rationale

Document
actual weight
using weighing
scale; do not
estimate

Patients may be
unaware of their
actual weight or
weight loss due to
estimating weight

Obtain
nutritional
history; include
family,
significant
others, or
caregiver in
assessment.

Patient's
perception of
actual intake may
differ.

Determine
etiologic
factors for
reduced
nutritional
intake

With proper
assessment you
may be able to
plan appropriate
interventions (i.e.,
patients with
dentation
problems may
require referral to
a dentist)

Many
psychological,

Evaluation

After 2 weeks of
nursing
intervention, goal
met. Patient was
able to verbalize
understanding
and demonstrate
selection of meals
that help in
achieving
cessation of
weight loss; and
gained at least
10% of ideal body
weight.

 Monitor or
explore
attitudes
toward eating
and food.

Encourage
patient
participation in
recording food
intake using a
daily log.

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

Determination of
type, amount, and
pattern of food or
fluid intake as
facilitated by
accurate
documentation by
patient or
caregiver as the
intake occurs;
memory is
insufficient.

Monitor patient
daily or weekly

During aggressive
nutritional
support, patient
can gain up to 0.5
lbs per day.

Provide
companionship
during

Attention to the
social aspects of
eating is
important in both

mealtime.

Build up and
persuade a
pleasing milieu
for meals. Dish
up foods in
well-ventilated,
pleasing
environment,
with unhurried
ambiance,
friendly
company.

Give
frequent
mouth care,
noting
secretion
precautions.
Prevent us of
alcoholcontaining
mouthwashes

Encourage

the hospital and

home setting.

Pleasing milieu
helps in lowering
stress and is more
favorable to
eating. It also
encourages
socialization and
maximizes patient
comfort when
eating difficulty
cause
discomfiture.

Lowers discomfort
related with
nausea or
vomiting, oral
lesions, mucosal
dryness, and
halitosis. Clean
mouth may
improve appetite

Metabolism and
utilization of
nutrients are

exercise as
indicated

Collaborative
Ask dietitian
for further
evaluation and
suggestions
regarding food
partialities and
nutritional
assistance.

enhanced by
activity.

Dietitians have a
broader
knowledge of the
nutritional value
of foods and may
be useful in
evaluating specific
ethnic or cultural
foods.