IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Taxonomy II: NutritionClass 1 Ingestion (00002) [Diagnostic Division: Food/Fluid] Submitted

1975; Revised 2000 Definition:Intake of nutrients insufficient to meet meta-bolic needs Related Factors Inability to ingest/digest food; inability to absorb nutrients Biological/psychological/economic factors [Increased metabolic demands, e.g., burns] [Lack of information, misinformation, misconceptions] Defining Characteristics SUBJECTIVE Reported food intake less than RDA (recommended daily allowances); lack of food Lack of interest in food; aversion to eating; reported altered taste sensation; perceived inability to digest food Satiety immediately after ingesting food Abdominal pain/cramping Lack of information, misinformation, misconceptions [Note: The authors view these as related factors rather than defining characteristics.] OBJECTIVE Body weight 20% or more under ideal [for height and frame]; [decreased subcutaneous fat/muscle mass] Loss of weight with adequate food intake Hyperactive bowel sounds; diarrhea; steatorrhea Weakness of muscles required for swallowing or mastication; poor muscle tone

Sore buccal cavity; pale mucous membranes; capillary fragility Excessive loss of hair [or increased growth of hair on body (lanugo)]; [cessation of menses] 478 Cultural Collaborative Community/Home Care Information in brackets added by the authors to clarify and enhance the use of nursing diagnoses. imbalanced NUTRITION: less than body requirements [Abnormal laboratory studies (e.g., decreased albumin, total proteins; iron deficiency; electrolyte imbalances)] Desired Outcomes/Evaluation CriteriaClient Will: Demonstrate progressive weight gain toward goal. Display normalization of laboratory values and be free of signs of malnutrition as reflected in Defining Characteristics. Verbalize understanding of causative factors when known and necessary interventions. Demonstrate behaviors, lifestyle changes to regain and/or maintain appropriate weight. Actions/Interventions NURSING PRIORITY NO.1.To assess causative/contributing factors: Identify client at risk for malnutrition (e.g., institutionalized elderly; client with chronic illness; child or adult living in poverty/low income area; client with jaw/facial injuries; intes-tinal surgery/post malabsorptive/restrictive surgical interven-tions for weight loss; hypermetabolic states [e.g., burns, hyperthroidism]; malabsorption syndromes/lactose intoler-ance; cystic fibrosis; pancreatic disease; prolonged time of restricted intake; prior nutritional deficiencies). Determine clients ability to chew, swallow, and taste food. Evaluate teeth and gums for poor oral health, and note den-ture fit, as indicated. All factors that can affect ingestion

and/or digestion of nutrients. Ascertain understanding of individual nutritional needs to determine informational needs of client/SO. Note availability/use of financial resources and support systems. Determine ability to acquire and store various types of food. Discuss eating habits, including food preferences, intoler-ances/aversions to appeal to clients likes/dislikes. Assess drug interactions, disease effects, allergies, use of laxa-tives, diuretics that may be affecting appetite, food intake, or absorption. Evaluate impact of cultural, ethnic, or religious desires/ influences that may affect food choices. Determine psychological factors/perform psychological assessment, as indicated,to assess body image and congru-ency with reality. Note occurrence of amenorrhea, tooth decay, swollen salivary glands, and report of constant sore throat,suggesting bulimia/ affecting ability to eat. Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 479 Information in brackets added by the authors to clarify and enhance the use of nursing diagnoses. imbalanced NUTRITION: less than body requirements Review usual activities/exercise program noting repetitive activities (e.g., constant pacing)/inappropriate exercise (e.g., prolonged jogging).May reveal obsessive nature of weight-control measures. NURSING PRIORITY NO.2.To evaluate degree of deficit: Assess weight; measure/calculate body fat and muscle mass via triceps skin fold and midarm muscle circumference or other anthropometric measurements to establish baseline parameters.

 Observe for absence of subcutaneous fat/muscle wasting, loss of hair, fissuring of nails, delayed healing, gum bleeding, swollen abdomen, etc.,that indicate protein-energy malnutrition. Auscultate bowel sounds. Note characteristics of stool (color, amount, frequency, etc.). Assist in nutritional assessment, using screening tools (e.g., Mini Nutritional Assessment [MNA]/similar tool). Review indicated laboratory data (e.g., serum albumin/preal-bumin, transferrin, amino acid profile, iron, BUN, nitrogen balance studies, glucose, liver function, electrolytes, total lym-phocyte count, indirect calorimetry). Assist with diagnostic procedures (e.g., Schillings test, D-xylose test, 72-hour stool fat, GI series). NURSING PRIORITY NO.3.To establish a nutritional plan that meets individual needs: Note age, body build, strength, activity/rest level, etc.Helps determine nutritional needs. Evaluate total daily food intake. Obtain diary of calorie intake, patterns and times of eating,to reveal possible cause of mal-nutrition/changes that could be made in clients intake. Calculate basal energy expenditure (BEE) using Harris-Benedict (or similar) formula and estimate energy and pro-tein requirements. Assist in treating/managing underlying causative factors (e.g., cancer, malabsorption syndrome, impaired cognition, depress-sion, medications that decrease appetite, fad diets, anorexia). Consult dietitian/nutritional team, as indicated,to imple-ment interdisciplinary team management. Provide diet modifications, as indicated. For example: Refer to nutritional resources to determine suitable ways to optimize clients intake of protein, carbohydrates, fats, calories within eating style/needs Several small meals and snacks daily

Mechanical soft or blenderized tube feedings 480 Cultural Collaborative Community/Home Care Information in brackets added by the authors to clarify and enhance the use of nursing diagnoses. imbalanced NUTRITION: less than body requirements Appetite stimulants (e.g., wine), if indicated High-calorie, nutrient-rich dietary supplements, such as meal replacement shake Formula tube feedings; parenteral nutrition infusion Administer pharmaceutical agents, as indicated: Digestive drugs/enzymes Vitamin/mineral (iron) supplements, including chewable multivitamin Medications (e.g., antacids, anticholinergics, antiemetics, antidiarrheals) Determine whether client prefers/tolerates more calories in a particular meal. Use flavoring agents (e.g., lemon and herbs) if salt is restricted to enhance food satisfaction and stimulate appetite. Encourage use of sugar/honey in beverages if carbohydrates are tolerated well. Encourage client to choose foods/have family member bring foods that seem appealing to stimulate appetite. Avoid foods that cause intolerances/increase gastric motility (e.g., foods that are gas-forming, hot/cold, or spicy; caffeinated beverages; milk products; and so forth), according to individ-ual needs. Limit fiber/bulk, if indicated,because it may lead to early satiety. Promote pleasant, relaxing environment, including socializa-tion when possible to enhance intake.

 Prevent/minimize unpleasant odors/sights.May have a nega-tive effect on appetite/eating. Assist with/provide oral care before and after meals and at bedtime. Encourage use of lozenges and so forth to stimulate saliva-tion when dryness is a factor. Promote adequate/timely fluid intake. Limit fluids 1 hour prior to mealto reduce possibility of early satiety. Weigh regularly/graph results to monitor effectiveness of efforts. Develop individual strategies when problem is mechanical (e.g., wired jaws or paralysis following stroke). Consult occu-pational therapist to identify appropriate assistive devices, or speech therapist to enhance swallowing ability. (Refer to ND impaired Swallowing.) Refer to structured (behavioral) program of nutrition ther-apy (e.g., documented time/length of eating period, blender-ized food/tube feeding, administered parenteral nutritional Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 481 Information in brackets added by the authors to clarify and enhance the use of nursing diagnoses. imbalanced NUTRITION: less than body requirements therapy, etc.) per protocol, particularly when problem is anorexia nervosa or bulimia. Recommend/support hospitalization for controlled environ-ment in severe malnutrition/life-threatening situations. Refer to social services/other community resources for possible assistance with clients limitations in buying/preparing foods. NURSING PRIORITY NO.4.To promote wellness (Teaching/Discharge Considerations): Emphasize importance of well-balanced, nutritious intake. Provide information regarding individual nutritional needs and ways to meet these needs within financial constraints.

 Develop behavior modification program with client involve-ment appropriate to specific needs. Provide positive regard, love, and acknowledgment of voice within guiding client with eating disorder. Develop consistent, realistic weight goal with client. Weigh at regular intervals and document results to monitor effectiveness of dietary plan. Consult with dietitian/nutritional support team, as necessary, for long-term needs. Develop regular exercise/stress reduction program. Review drug regimen, side effects, and potential interactions with other medications/over-the-counter drugs. Review medical regimen and provide information/assistance, as necessary. Assist client to identify/access resources, such as way to obtain nutrient-dense low budget foods, food stamps, Meals on Wheels, community food banks, and/or other appropriate assistance programs. Refer for dental hygiene/professional care, counseling/psychi-atric care, family therapy, as indicated. Provide/reinforce client teaching regarding preoperative and postoperative dietary needs when surgery is planned. Assist client/SO(s) to learn how to blenderize food and/or perform tube feeding. Refer to home health resources for initiation/supervision of home nutrition therapy when used. Documentation Focus ASSESSMENT/REASSESSMENT Baseline and subsequent assessment findings to include signs/symptoms as noted in Defining Characteristics and lab-oratory diagnostic findings. 482 Cultural Collaborative Community/Home Care

Information in brackets added by the authors to clarify and enhance the use of nursing diagnoses. imbalanced NUTRITION: less than body requirements Caloric intake. Individual cultural/religious restrictions, personal prefer-ences. Availability/use of resources. Personal understanding/perception of problem. PLANNING Plan of care and who is involved in planning. Teaching plan. IMPLEMENTATION/EVALUATION Clients responses to interventions/teaching and actions per-formed. Results of periodic weigh-in. Attainment/progress toward desired outcome(s). Modifications to plan of care. DISCHARGE PLANNING Long-term needs/who is responsible for actions to be taken. Specific referrals made.