Imbalanced Nutrition: Less than Body Requirements

Nursing diagnosis: Imbalanced Nutrition: Less than Body Requirements related to altered ability to ingest and properly digest food; increased metabolic demands

Possibly evidenced by

Weight loss and poor muscle tone

Aversion to eating; reported altered taste sensation

Sore, inflamed buccal cavity

Absence of or hyperactive bowel sounds

Desired Outcomes/Evaluation Criteria—Client Will

Nutritional Status

Indicate understanding of individual dietary needs.

Demonstrate progressive weight gain toward goal with normalization of laboratory values.

Nursing intervention with rationale:

1. Evaluate ability to eat.

Rationale: Client with a tracheostomy tube may be able to eat, but client with ET tube must be tube fed or parenterally nourished.

2. Observe and monitor for generalized muscle wasting and loss of subcutaneous fat.

Rationale: These symptoms are indicative of depletion of muscle energy and can reduce respiratory muscle function.

3. Weigh, as indicated.

Rationale: Significant and recent weight loss (7% to 10% body weight) and poor nutritional intake provide clues regarding catabolism, muscle glycogen stores, and ventilatory drive

sensitivity.

4. Document oral intake if and when resumed. Offer foods that client enjoys.

Rationale: Appetite is usually poor and intake of essential nutrients may be reduced. Offering favorite foods can enhance oral intake.

5. Provide small frequent feedings of soft and easily digested foods if able to swallow.

Rationale: Prevents excessive fatigue, enhances intake, and reduces risk of gastric distress.

6. Encourage or administer fluid intake of at least 2,500 mL/day within cardiac tolerance.

Rationale: Prevents dehydration that can be exacerbated by increased insensible losses (ventilator or intubation) and reduces risk of constipation.

7. Assess GI function: presence and quality of bowel sounds and changes in abdominal girth, nausea, and vomiting. Observe and document changes in bowel movements, such as diarrhea

and constipation. Test all stools for occult blood.

Rationale: A functioning GI system is essential for the proper utilization of enteral feedings. Mechanically ventilated clients are at risk of developing abdominal distention (trapped air or

ileus) and gastric bleeding (stress ulcers).

8. Adjust diet to meet respiratory needs, as indicated.

Rationale: High intake of carbohydrates, protein, and calories may be desired or needed during ventilation to improve respiratory muscle function. Carbohydrates may be reduced and fat somewhat increased just before weaning attempts to prevent excessive CO2 production and reduced respiratory drive.

9. Administer tube feeding or hyperalimentation, as needed.

Rationale: Provides adequate nutrients to meet individual needs when oral intake is insufficient or not appropriate.

10. Monitor laboratory studies as indicated, such as prealbumin, serum transferrin, BUN/Cr, and glucose.

Rationale: Provides information about adequacy of nutritional support or need for change.