Nursing diagnosis: imbalanced Nutrition: Less than Body Requirements related to gastrointestinal (GI) disturbances (result of uremia or medication side effects)—anorexia, nausea, vomiting, and stomatitis, sensation of feeling full—abdominal distention during continuous ambulatory peritoneal dialysis (CAPD), dietary restrictions—bland, tasteless food; lack of interest in food, loss of peptides and amino acids (building blocks for proteins) during dialysis
Possibly evidenced by
Inadequate food intake, aversion to eating, altered taste sensation
Poor muscle tone, weakness
Sore, inflamed buccal cavity; pale conjunctiva and mucous membranes
Desired Outcomes/Evaluation Criteria—Client Will
Nutritional Status
Demonstrate stable weight or gain toward goal with normalization of laboratory values and no signs of malnutrition.
Nursing intervention with rationale:
1. Monitor food and fluid ingested and calculate daily caloric intake.
Rationale: Identifies nutritional deficits and therapy needs, which are extremely variable, depending on client’s age, stage of renal disease, other coexisting conditions, and the type of dialysis being planned.
2. Recommend client/significant other (SO) keep a food diary, including estimation of ingested calories, protein, and electrolytes of individual concern—sodium, potassium, chloride, magnesium, and phosphorus.
Rationale: Helps client realize “big picture” and allows opportunity to alter dietary choices to meet individual desires within identified restriction.
3. Note presence of nausea and anorexia.
Rationale: Symptoms accompany accumulation of endogenous toxins that can alter or reduce intake and require intervention.
4. Encourage client to participate in menu planning.
Rationale: May enhance oral intake and promote sense of control.
5. Recommend small, frequent meals. Schedule meals according to dialysis needs.
Rationale: Smaller portions may enhance intake. Type of dialysis influences meal patterns; for instance, clients receiving HD might not be fed directly before or during procedure because this can alter fluid removal, and clients undergoing PD may be unable to ingest food while abdomen is distended with dialysate.
6. Encourage use of herbs and spices such as garlic, onion, pepper, parsley, cilantro, and lemon.
Rationale: Adds zest to food to help reduce boredom with diet, while reducing potential for ingesting too much potassium and sodium.
7. Suggest socialization during meals.
Rationale: Provides diversion and promotes social aspects of eating.
8. Encourage frequent mouth care.
Rationale: Reduces discomfort of oral stomatitis and metallic taste in mouth associated with uremia, which can interfere with food intake.
9. Refer to nutritionist or dietitian to develop diet appropriate to client’s needs.
Rationale: Necessary to develop complex and highly individual dietary program to meet cultural and lifestyle needs within specific kilocalorie and protein restrictions while controlling phosphorus, sodium, and potassium.
10. Provide a balanced diet, usually of 2,000 to 2,200 calories/day of complex carbohydrates and ordered amount of high-quality protein and essential amino acids.
Rationale: Provides sufficient nutrients to improve energy and prevent muscle wasting (catabolism); promotes tissue regeneration and healing and electrolyte balance. Although client with kidney disease is often advised to limit protein intake, that changes with the start of dialysis. Protein-rich foods, such as fresh meats, poultry, fish and other seafood, eggs and egg whites, and small servings of dairy products are needed for building muscles, repairing tissue, and fighting infection. However, some protein-rich foods may contain a high level of phosphorus, so a dietitian’s input is essential in determining the right amount to eat (Paton, 2007).
Showing posts with label Imbalanced Nutrition: Less than Body Requirements. Show all posts
Showing posts with label Imbalanced Nutrition: Less than Body Requirements. Show all posts
Saturday, May 28, 2011
Tuesday, May 24, 2011
Risk for Imbalanced Nutrition: Less than Body Requirements | Nursing Diagnosis for Renal Failure
Nursing diagnosis: risk for imbalanced Nutrition: Less than Body Requirements
Risk factors may include
Protein catabolism, dietary restrictions to reduce nitrogenous waste products
Increased metabolic needs
Anorexia, nausea and vomiting, ulcerations of oral mucosa
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Nutritional Status
Maintain or regain weight as indicated by individual situation; be free of edema.
Nursing intervention with rationale:
1. Assess and document dietary intake.
Rationale: Aids in identifying deficiencies and dietary needs. Uremic symptoms (such as, nausea, anorexia, altered taste) and multiple dietary restrictions affect food intake.
2. Provide frequent, small feedings.
Rationale: Minimizes anorexia and nausea associated with uremic state and diminished peristalsis.
3. Give client and SO a list of permitted foods and fluids and encourage involvement in menu choices.
Rationale: Provides client with a measure of control within dietary restrictions. Food from home may enhance appetite.
4. Offer frequent mouth care and rinse with dilute (0.25%) acetic acid solution; provide gum, hard candy, or breath mints between meals.
Rationale: Mucous membranes may become dry and cracked. Mouth care soothes, lubricates, and helps freshen mouth taste, which is often unpleasant because of uremia and restricted oral intake. Rinsing with acetic acid helps neutralize ammonia formed by conversion of urea.
5. Weigh daily, preferably in the morning before breakfast.
Rationale: The fasting and catabolic client normally loses 0.2 to 0.5 kg/day. Changes in excess of 0.5 kg may reflect shifts in fluid balance.
6. Monitor laboratory studies, such as BUN, prealbumin or albumin, transferrin, sodium, and potassium.
Rationale: Indicators of nutritional needs, restrictions, and necessity for, and effectiveness of, therapy.
7. Consult with dietitian or nutritional support team.
Rationale: Determines individual calorie and nutrient needs within the restrictions and identifies most effective route and product—oral supplements, enteral or parenteral nutrition.
8. Provide high-calorie, low- or moderate-protein diet. Include complex carbohydrates and fat sources to meet caloric needs (avoiding concentrated sugar sources) and to provide essential amino acids.
Rationale: The amount of needed exogenous protein is less than normal unless client is on dialysis. Carbohydrates meet energy needs and limit tissue catabolism, preventing ketoacid formation from protein and fat oxidation. Carbohydrate intolerance mimicking diabetes mellitus may occur in severe renal failure. Essential amino acids improve nitrogen balance and nutritional status, stimulate repair of tubular epithelial cells, and enhance client’s ability to fight systemic complications.
9. Restrict potassium, sodium, and phosphorus intake, as indicated.
Rationale: Restriction of these electrolytes may be needed to prevent further renal damage, especially if dialysis is not part of treatment, and during recovery phase of ARF.
10. Administer medications as indicated, for example: Iron preparations
Rationale: Iron deficiency may occur if protein is restricted, client is anemic, or GI function is impaired.
Risk factors may include
Protein catabolism, dietary restrictions to reduce nitrogenous waste products
Increased metabolic needs
Anorexia, nausea and vomiting, ulcerations of oral mucosa
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Nutritional Status
Maintain or regain weight as indicated by individual situation; be free of edema.
Nursing intervention with rationale:
1. Assess and document dietary intake.
Rationale: Aids in identifying deficiencies and dietary needs. Uremic symptoms (such as, nausea, anorexia, altered taste) and multiple dietary restrictions affect food intake.
2. Provide frequent, small feedings.
Rationale: Minimizes anorexia and nausea associated with uremic state and diminished peristalsis.
3. Give client and SO a list of permitted foods and fluids and encourage involvement in menu choices.
Rationale: Provides client with a measure of control within dietary restrictions. Food from home may enhance appetite.
4. Offer frequent mouth care and rinse with dilute (0.25%) acetic acid solution; provide gum, hard candy, or breath mints between meals.
Rationale: Mucous membranes may become dry and cracked. Mouth care soothes, lubricates, and helps freshen mouth taste, which is often unpleasant because of uremia and restricted oral intake. Rinsing with acetic acid helps neutralize ammonia formed by conversion of urea.
5. Weigh daily, preferably in the morning before breakfast.
Rationale: The fasting and catabolic client normally loses 0.2 to 0.5 kg/day. Changes in excess of 0.5 kg may reflect shifts in fluid balance.
6. Monitor laboratory studies, such as BUN, prealbumin or albumin, transferrin, sodium, and potassium.
Rationale: Indicators of nutritional needs, restrictions, and necessity for, and effectiveness of, therapy.
7. Consult with dietitian or nutritional support team.
Rationale: Determines individual calorie and nutrient needs within the restrictions and identifies most effective route and product—oral supplements, enteral or parenteral nutrition.
8. Provide high-calorie, low- or moderate-protein diet. Include complex carbohydrates and fat sources to meet caloric needs (avoiding concentrated sugar sources) and to provide essential amino acids.
Rationale: The amount of needed exogenous protein is less than normal unless client is on dialysis. Carbohydrates meet energy needs and limit tissue catabolism, preventing ketoacid formation from protein and fat oxidation. Carbohydrate intolerance mimicking diabetes mellitus may occur in severe renal failure. Essential amino acids improve nitrogen balance and nutritional status, stimulate repair of tubular epithelial cells, and enhance client’s ability to fight systemic complications.
9. Restrict potassium, sodium, and phosphorus intake, as indicated.
Rationale: Restriction of these electrolytes may be needed to prevent further renal damage, especially if dialysis is not part of treatment, and during recovery phase of ARF.
10. Administer medications as indicated, for example: Iron preparations
Rationale: Iron deficiency may occur if protein is restricted, client is anemic, or GI function is impaired.
Friday, May 13, 2011
Imbalanced Nutrition: Less than Body Requirements | Nursing Care Plan Anemia
Nursing diagnosis: imbalanced Nutrition: Less than Body Requirements related to Failure to ingest or inability to digest food or absorb nutrients necessary for formation of normal RBCs
Possibly evidenced by
Weight loss or weight below normal for age, height, and build
Decreased triceps skinfold measurement
Changes in gums, oral mucous membranes
Decreased tolerance for activity, weakness, and loss of muscle tone
Desired Outcomes/Evaluation Criteria—Client Will
Nutritional Status
Demonstrate progressive weight gain or stable weight, with normalization of laboratory values.
Experience no signs of malnutrition.
Demonstrate behaviors or lifestyle changes to regain and maintain appropriate weight.
Nursing intervention with rationale:
1. Review nutritional history, including food preferences.
Rationale: Identifies deficiencies and suggests possible interventions. Note: Daily meal diary over period of time may be necessary to identify anemia related to nutrient deficiencies such as no meat in diet—iron and vitamin B12 deficiency, or few leafy vegetables in diet—folic acid deficiency.
2. Observe and record client’s food intake.
Rationale: Monitors caloric intake or insufficient quality of food consumption.
3. Weigh periodically as appropriate, such as weekly.
Rationale: Monitors weight loss and effectiveness of nutritional interventions.
4. Recommend small, frequent meals and between-meal nourishment.
Rationale: May reduce fatigue and thus enhance intake while preventing gastric distention. Use of Ensure, Isomil, or similar product provides additional protein and calories.
5. Suggest bland diet, low in roughage, avoiding hot, spicy, or very acidic foods, as indicated.
Rationale: When oral lesions are present, pain may restrict type of foods client can tolerate.
6. Have client record and report occurrence of nausea or vomiting, flatus, and other related symptoms, such as irritability or impaired memory.
Rationale: May reflect effects of anemias, such as hypoxia or vitamin B12 deficiency, on organs.
7. Encourage or assist with good oral hygiene before and after meals; use soft-bristled toothbrush for gentle brushing. Provide dilute, alcohol-free mouthwash if oral mucosa is ulcerated.
Rationale: Enhances appetite and oral intake. Diminishes bacterial growth, minimizing possibility of infection. Special mouth-care techniques may be needed if tissue is fragile, ulcerated, or bleeding and pain is severe.
8. Consult with dietitian.
Rationale: Aids in establishing dietary plan to meet individual needs.
9. Monitor laboratory studies, such as Hgb/Hct, blood urea nitrogen (BUN), prealbumin and albumin, protein, transferrin, serum iron, vitamin B12, folic acid, TIBC, and serum electrolytes.
Rationale: Evaluates effectiveness of treatment regimen, including dietary sources of needed nutrients.
10. Administer medications, as indicated, for example: Vitamin and mineral supplements, such as cyanocobalamin (vitamin B12), folic acid (Folvite), and ascorbic acid (vitamin C)
Rationale: Replacements needed depend on type of anemia and presence of poor oral intake and identified deficiencies.
Possibly evidenced by
Weight loss or weight below normal for age, height, and build
Decreased triceps skinfold measurement
Changes in gums, oral mucous membranes
Decreased tolerance for activity, weakness, and loss of muscle tone
Desired Outcomes/Evaluation Criteria—Client Will
Nutritional Status
Demonstrate progressive weight gain or stable weight, with normalization of laboratory values.
Experience no signs of malnutrition.
Demonstrate behaviors or lifestyle changes to regain and maintain appropriate weight.
Nursing intervention with rationale:
1. Review nutritional history, including food preferences.
Rationale: Identifies deficiencies and suggests possible interventions. Note: Daily meal diary over period of time may be necessary to identify anemia related to nutrient deficiencies such as no meat in diet—iron and vitamin B12 deficiency, or few leafy vegetables in diet—folic acid deficiency.
2. Observe and record client’s food intake.
Rationale: Monitors caloric intake or insufficient quality of food consumption.
3. Weigh periodically as appropriate, such as weekly.
Rationale: Monitors weight loss and effectiveness of nutritional interventions.
4. Recommend small, frequent meals and between-meal nourishment.
Rationale: May reduce fatigue and thus enhance intake while preventing gastric distention. Use of Ensure, Isomil, or similar product provides additional protein and calories.
5. Suggest bland diet, low in roughage, avoiding hot, spicy, or very acidic foods, as indicated.
Rationale: When oral lesions are present, pain may restrict type of foods client can tolerate.
6. Have client record and report occurrence of nausea or vomiting, flatus, and other related symptoms, such as irritability or impaired memory.
Rationale: May reflect effects of anemias, such as hypoxia or vitamin B12 deficiency, on organs.
7. Encourage or assist with good oral hygiene before and after meals; use soft-bristled toothbrush for gentle brushing. Provide dilute, alcohol-free mouthwash if oral mucosa is ulcerated.
Rationale: Enhances appetite and oral intake. Diminishes bacterial growth, minimizing possibility of infection. Special mouth-care techniques may be needed if tissue is fragile, ulcerated, or bleeding and pain is severe.
8. Consult with dietitian.
Rationale: Aids in establishing dietary plan to meet individual needs.
9. Monitor laboratory studies, such as Hgb/Hct, blood urea nitrogen (BUN), prealbumin and albumin, protein, transferrin, serum iron, vitamin B12, folic acid, TIBC, and serum electrolytes.
Rationale: Evaluates effectiveness of treatment regimen, including dietary sources of needed nutrients.
10. Administer medications, as indicated, for example: Vitamin and mineral supplements, such as cyanocobalamin (vitamin B12), folic acid (Folvite), and ascorbic acid (vitamin C)
Rationale: Replacements needed depend on type of anemia and presence of poor oral intake and identified deficiencies.
Thursday, May 5, 2011
Imbalanced Nutrition: Less than Body Requirements | NCP Total Nutritional Support
Nursing diagnosis: imbalanced Nutrition: Less than Body Requirements related to Conditions that interfere with nutrient intake or increase nutrient need or metabolic demand—cancer and associated treatments, anorexia, surgical procedures, dysphagia, or decreased level of consciousness
Possibly evidenced by
Body weight 10% or more under ideal
Decreased subcutaneous fat or muscle mass, poor muscle tone
Changes in gastric motility and stool characteristics
Desired Outcomes/Evaluation Criteria—Client Will
Nutritional Status
Demonstrate stable weight or progressive weight gain toward goal, with normalization of laboratory values and no signs of malnutrition.
Nursing intervention with rationale:
1. Assess nutritional status continually during daily nursing care, noting energy level; condition of skin, nails, hair, oral cavity; and desire to eat.
Rationale: Provides the opportunity to observe deviations from normal client baseline and influences choice of interventions.
2. Weigh daily and compare with admission weight.
Rationale: Establishes baseline, aids in monitoring effectiveness of therapeutic regimen, and alerts nurse to inappropriate trends in weight loss or gain.
3. Document oral intake by use of 24-hour recall, food history, and calorie counts, as appropriate.
Rationale: Identifies imbalance between estimated nutritional requirements and actual intake.
4. Ensure accurate collection of specimens (urine and stool) for nitrogen balance studies.
Rationale: Inaccurate collection can alter test results, leading to improper interpretation of client’s current status and needs.
5. Administer nutritional solutions at prescribed rate via infusion control device, as needed. Adjust rate to deliver prescribed hourly intake. Do not increase rate to “catch up” if infusion slows.
Rationale: Nutritional support prescriptions are based on individually estimated caloric and protein requirements. A consistent rate of nutrient administration ensures proper utilization with fewer side effects, such as hyperglycemia or dumping syndrome. Note: Continuous and cyclic infusions of enteral formulas are generally better tolerated than bolus feedings and result in improved absorption.
6. Be familiar with electrolyte content of nutritional solutions.
Rationale: Metabolic complications of nutritional support often result from a lack of appreciation of changes that can occur because of refeeding—hyperglycemia, hyperosmolar nonketotic coma (HHNC), and electrolyte imbalances.
7. Schedule activities with adequate rest periods. Promote relaxation techniques.
Rationale: Conserves energy and reduces calorie needs.
8. Observe appropriate “hang” time of parenteral solutions per protocol.
Rationale: Effectiveness of IV vitamins diminishes and solution degrades after 24 hours.
9. Monitor fingerstick glucose per protocol, such as four times per day (JCAHO, 1997; Moghissi, 2009) during initiation of therapy.
Rationale: High glucose content of solutions may lead to pancreatic fatigue, requiring use of supplemental insulin to prevent hyperglycemic complications. Note: Fingerstick determination of glucose level is more accurate than urine testing because of variations in renal glucose threshold.
10. Assess GI function and tolerance to enteral feedings, knowing type of tube used, such as NG or small bowel. Note bowel sounds, reports of nausea and abdominal discomfort, presence of diarrhea or constipation, development of weakness, lightheadedness, diaphoresis, tachycardia, and abdominal cramping.
Rationale: Because protein turnover of the GI mucosa occurs approximately every 3 days, the GI tract is at great risk for early dysfunction and atrophy from disease and malnutrition. Intolerance of formula or presence of dumping syndrome may require alteration of rate of administration, concentration or type of formula, or possibly change to parenteral administration. Note: Use of postpyloric feeding tube eliminates need for active bowel sounds as a criterion for tolerance.
Possibly evidenced by
Body weight 10% or more under ideal
Decreased subcutaneous fat or muscle mass, poor muscle tone
Changes in gastric motility and stool characteristics
Desired Outcomes/Evaluation Criteria—Client Will
Nutritional Status
Demonstrate stable weight or progressive weight gain toward goal, with normalization of laboratory values and no signs of malnutrition.
Nursing intervention with rationale:
1. Assess nutritional status continually during daily nursing care, noting energy level; condition of skin, nails, hair, oral cavity; and desire to eat.
Rationale: Provides the opportunity to observe deviations from normal client baseline and influences choice of interventions.
2. Weigh daily and compare with admission weight.
Rationale: Establishes baseline, aids in monitoring effectiveness of therapeutic regimen, and alerts nurse to inappropriate trends in weight loss or gain.
3. Document oral intake by use of 24-hour recall, food history, and calorie counts, as appropriate.
Rationale: Identifies imbalance between estimated nutritional requirements and actual intake.
4. Ensure accurate collection of specimens (urine and stool) for nitrogen balance studies.
Rationale: Inaccurate collection can alter test results, leading to improper interpretation of client’s current status and needs.
5. Administer nutritional solutions at prescribed rate via infusion control device, as needed. Adjust rate to deliver prescribed hourly intake. Do not increase rate to “catch up” if infusion slows.
Rationale: Nutritional support prescriptions are based on individually estimated caloric and protein requirements. A consistent rate of nutrient administration ensures proper utilization with fewer side effects, such as hyperglycemia or dumping syndrome. Note: Continuous and cyclic infusions of enteral formulas are generally better tolerated than bolus feedings and result in improved absorption.
6. Be familiar with electrolyte content of nutritional solutions.
Rationale: Metabolic complications of nutritional support often result from a lack of appreciation of changes that can occur because of refeeding—hyperglycemia, hyperosmolar nonketotic coma (HHNC), and electrolyte imbalances.
7. Schedule activities with adequate rest periods. Promote relaxation techniques.
Rationale: Conserves energy and reduces calorie needs.
8. Observe appropriate “hang” time of parenteral solutions per protocol.
Rationale: Effectiveness of IV vitamins diminishes and solution degrades after 24 hours.
9. Monitor fingerstick glucose per protocol, such as four times per day (JCAHO, 1997; Moghissi, 2009) during initiation of therapy.
Rationale: High glucose content of solutions may lead to pancreatic fatigue, requiring use of supplemental insulin to prevent hyperglycemic complications. Note: Fingerstick determination of glucose level is more accurate than urine testing because of variations in renal glucose threshold.
10. Assess GI function and tolerance to enteral feedings, knowing type of tube used, such as NG or small bowel. Note bowel sounds, reports of nausea and abdominal discomfort, presence of diarrhea or constipation, development of weakness, lightheadedness, diaphoresis, tachycardia, and abdominal cramping.
Rationale: Because protein turnover of the GI mucosa occurs approximately every 3 days, the GI tract is at great risk for early dysfunction and atrophy from disease and malnutrition. Intolerance of formula or presence of dumping syndrome may require alteration of rate of administration, concentration or type of formula, or possibly change to parenteral administration. Note: Use of postpyloric feeding tube eliminates need for active bowel sounds as a criterion for tolerance.
Monday, May 2, 2011
Imbalanced Nutrition: Less than Body Requirements | NCP Pancreatitis
Nursing diagnosis: imbalanced Nutrition: Less than Body Requirements related to Vomiting, decreased oral intake; prescribed dietary restrictions, Loss of digestive enzymes (related to pancreatic outflow obstruction, necrosis, or autodigestion)
Possibly evidenced by
Reported inadequate food intake
Aversion to eating, reported altered taste sensation, lack of interest in food
Weight loss
Poor muscle tone
Desired Outcomes/Evaluation Criteria—Client Will
Nutritional Status
Demonstrate progressive weight gain toward goal with normalization of laboratory values.
Experience no signs of malnutrition.
Knowledge: Diet
Demonstrate behaviors or lifestyle changes to regain and maintain appropriate weight.
Nursing intervention with rationale:
1. Assess abdomen, noting presence and character of bowel sounds, abdominal distention, and reports of nausea.
Rationale: Gastric distention and intestinal atony are frequently present, resulting in reduced or absent bowel sounds. Return of bowel sounds and relief of symptoms signal readiness for discontinuation of NG.
2. Provide frequent oral care.
Rationale: Decreases vomiting stimulus and soothes inflamed, dry mucous membranes associated with dehydration and mouth breathing when NG tube is in place.
3. Assist client in selecting food and fluids that meet nutritional needs and restrictions when diet is resumed.
Rationale: Previous dietary habits may be unsatisfactory in meeting current needs for tissue regeneration and healing. Use of gastric stimulants, such as caffeine, alcohol, cigarettes, or gas-producing foods, or ingestion of large meals may result in excessive stimulation of the pancreas and recurrence of symptoms.
4. Observe color, consistency, and amount of stools. Note frothy consistency and foul odor.
Rationale: Steatorrhea may develop from incomplete digestion of fats.
5. Maintain NPO status and gastric suctioning during acute phase.
Rationale: Prevents stimulation and release of pancreatic enzymes (secretin) when chyme and hydrochloric acid enter the duodenum.
6. Resume oral intake with liquids and advance diet slowly to provide high-protein, high-carbohydrate diet, when indicated.
Rationale: Oral feedings given too early in the course of illness may exacerbate symptoms.
7. Provide medium-chain triglycerides (MCTs), such as Portagen.
Rationale: MCTs are elements of enteral feeding that provide supplemental calories or nutrients that do not require pancreatic enzymes for digestion and absorption.
8. Administer enteral or parenteral feedings, as indicated.
Rationale: Enteral feedings may be preferred to prevent gut atrophy when tolerated; however, IV administration of calories, lipids, and amino acids should be instituted before nitrogen depletion is advanced.
9. Administer medications, as indicated, for example: Vitamins, such as A, D, E, and K
Rationale: Replacement required because fat metabolism is altered, reducing absorption and storage of fat-soluble vitamins.
10. Replacement enzymes, such as pancreatin (Dizymes) and pancrelipase (Protilase, Cotazym)
Rationale: Used in chronic pancreatitis to correct deficiencies to promote digestion and absorption of nutrients.
Possibly evidenced by
Reported inadequate food intake
Aversion to eating, reported altered taste sensation, lack of interest in food
Weight loss
Poor muscle tone
Desired Outcomes/Evaluation Criteria—Client Will
Nutritional Status
Demonstrate progressive weight gain toward goal with normalization of laboratory values.
Experience no signs of malnutrition.
Knowledge: Diet
Demonstrate behaviors or lifestyle changes to regain and maintain appropriate weight.
Nursing intervention with rationale:
1. Assess abdomen, noting presence and character of bowel sounds, abdominal distention, and reports of nausea.
Rationale: Gastric distention and intestinal atony are frequently present, resulting in reduced or absent bowel sounds. Return of bowel sounds and relief of symptoms signal readiness for discontinuation of NG.
2. Provide frequent oral care.
Rationale: Decreases vomiting stimulus and soothes inflamed, dry mucous membranes associated with dehydration and mouth breathing when NG tube is in place.
3. Assist client in selecting food and fluids that meet nutritional needs and restrictions when diet is resumed.
Rationale: Previous dietary habits may be unsatisfactory in meeting current needs for tissue regeneration and healing. Use of gastric stimulants, such as caffeine, alcohol, cigarettes, or gas-producing foods, or ingestion of large meals may result in excessive stimulation of the pancreas and recurrence of symptoms.
4. Observe color, consistency, and amount of stools. Note frothy consistency and foul odor.
Rationale: Steatorrhea may develop from incomplete digestion of fats.
5. Maintain NPO status and gastric suctioning during acute phase.
Rationale: Prevents stimulation and release of pancreatic enzymes (secretin) when chyme and hydrochloric acid enter the duodenum.
6. Resume oral intake with liquids and advance diet slowly to provide high-protein, high-carbohydrate diet, when indicated.
Rationale: Oral feedings given too early in the course of illness may exacerbate symptoms.
7. Provide medium-chain triglycerides (MCTs), such as Portagen.
Rationale: MCTs are elements of enteral feeding that provide supplemental calories or nutrients that do not require pancreatic enzymes for digestion and absorption.
8. Administer enteral or parenteral feedings, as indicated.
Rationale: Enteral feedings may be preferred to prevent gut atrophy when tolerated; however, IV administration of calories, lipids, and amino acids should be instituted before nitrogen depletion is advanced.
9. Administer medications, as indicated, for example: Vitamins, such as A, D, E, and K
Rationale: Replacement required because fat metabolism is altered, reducing absorption and storage of fat-soluble vitamins.
10. Replacement enzymes, such as pancreatin (Dizymes) and pancrelipase (Protilase, Cotazym)
Rationale: Used in chronic pancreatitis to correct deficiencies to promote digestion and absorption of nutrients.
Saturday, April 23, 2011
Imbalanced Nutrition: Less than Body Requirements | NCP Liver Cirrhosis
Nursing diagnosis: imbalanced Nutrition: Less than Body Requirements related to Inadequate diet; inability to process, digest nutrients, Anorexia, nausea, vomiting, indigestion, early satiety (ascites), Abnormal bowel function
Possibly evidenced by
Weight loss
Changes in bowel sounds and function
Poor muscle tone, muscle wasting; fatigue
Imbalances in nutritional studies
Desired Outcomes/Evaluation Criteria—Client Will
Nutritional Status
Demonstrate progressive weight gain toward goal with client-appropriate normalization of laboratory values.
Experience no further signs of malnutrition.
Nursing intervention with rationale:
1. Evaluate client’s risk for malnutrition.
Rationale: Eighty-five percent to 90% of the blood that leaves the stomach and intestines carries nutrients to the liver where they are converted into substances the body can use. The client with liver dysfunction often has malnutrition because of inadequate dietary intake due to poor food choices or preference for alcohol rather than food and may currently have malabsorption syndrome due to inability to process or digest nutrients, anorexia, nausea or vomiting, indigestion, or early satiety associated with ascites. Because of the decreased secretion of bile into the gut, client may have difficulty absorbing fat and fat-soluble vitamins A, D, E, and K. These deficiencies can lead to such complications as decreased vision in the dark, due to vitamin A deficiency; bone disease, due to vitamin D deficiency; neurological impairment, due to vitamin E deficiency; and decreased production of clotting proteins in the liver, due to vitamin K deficiency (Brettler, 2003).
2. Determine interest in eating and ability to chew, swallow, and taste. Discuss eating habits, including food preferences, intolerances, or aversions. Note availability and use of support systems.
Rationale: Factors that affect ingestion and digestion of nutrients.
3. Determine dietary intake and perform calorie count if client is eating.
Rationale: Provides information about intake, needs, and deficiencies. Client with cirrhosis requires a balanced protein diet providing 2,000 to 3,000 calories per day to permit liver cell regeneration.
4. Weigh, as indicated. Compare changes in fluid status and recent weight history.
Rationale: It may be difficult to use weight as a direct indicator of nutritional status in view of edema and ascites. Note: Undigested fat that passes into the large intestine can cause diarrhea and lead to weight loss (Brettler, 2003).
5. Assist or encourage client to eat; explain reasons for the types of diet. Feed client if tiring easily, or have SO assist client. Consider preferences in food choices.
Rationale: Improved nutrition is vital to recovery. Client may eat better if family is involved and preferred foods are included as much as possible. Client and family must understand protein intake limitations and how best to meet needs and desires within limitations.
6. Encourage client to eat all meals and supplementary feedings.
Rationale: Client may demonstrate loss of interest in food because of nausea, generalized weakness, and fatigue—which is often first reported symptom and seen in approximately 70% of clients with cirrhosis (Taylor, 2008).
7. Recommend or provide small, frequent meals.
Rationale: Poor tolerance to larger meals may be due to increased intraabdominal pressure or ascites.
8. Limit such high-salt foods as canned soups and vegetables, processed meats, and condiments. Provide salt substitutes if allowed, avoiding those containing ammonia.
Rationale: Salt limitations can help manage fluid complications in cirrhosis, including ascites or tissue edema. Salt substitutes enhance the flavor of food and aid in increasing appetite; ammonia potentiates risk of encephalopathy.
9. Restrict intake of caffeine and gas-producing or spicy and excessively hot or cold foods.
Rationale: Aids in reducing gastric irritation, diarrhea, and abdominal discomfort that may impair oral intake and digestion.
10. Encourage or provide frequent mouth care, especially before meals.
Rationale: Client is prone to sore and bleeding gums and bad taste in mouth, which contributes to anorexia.
Possibly evidenced by
Weight loss
Changes in bowel sounds and function
Poor muscle tone, muscle wasting; fatigue
Imbalances in nutritional studies
Desired Outcomes/Evaluation Criteria—Client Will
Nutritional Status
Demonstrate progressive weight gain toward goal with client-appropriate normalization of laboratory values.
Experience no further signs of malnutrition.
Nursing intervention with rationale:
1. Evaluate client’s risk for malnutrition.
Rationale: Eighty-five percent to 90% of the blood that leaves the stomach and intestines carries nutrients to the liver where they are converted into substances the body can use. The client with liver dysfunction often has malnutrition because of inadequate dietary intake due to poor food choices or preference for alcohol rather than food and may currently have malabsorption syndrome due to inability to process or digest nutrients, anorexia, nausea or vomiting, indigestion, or early satiety associated with ascites. Because of the decreased secretion of bile into the gut, client may have difficulty absorbing fat and fat-soluble vitamins A, D, E, and K. These deficiencies can lead to such complications as decreased vision in the dark, due to vitamin A deficiency; bone disease, due to vitamin D deficiency; neurological impairment, due to vitamin E deficiency; and decreased production of clotting proteins in the liver, due to vitamin K deficiency (Brettler, 2003).
2. Determine interest in eating and ability to chew, swallow, and taste. Discuss eating habits, including food preferences, intolerances, or aversions. Note availability and use of support systems.
Rationale: Factors that affect ingestion and digestion of nutrients.
3. Determine dietary intake and perform calorie count if client is eating.
Rationale: Provides information about intake, needs, and deficiencies. Client with cirrhosis requires a balanced protein diet providing 2,000 to 3,000 calories per day to permit liver cell regeneration.
4. Weigh, as indicated. Compare changes in fluid status and recent weight history.
Rationale: It may be difficult to use weight as a direct indicator of nutritional status in view of edema and ascites. Note: Undigested fat that passes into the large intestine can cause diarrhea and lead to weight loss (Brettler, 2003).
5. Assist or encourage client to eat; explain reasons for the types of diet. Feed client if tiring easily, or have SO assist client. Consider preferences in food choices.
Rationale: Improved nutrition is vital to recovery. Client may eat better if family is involved and preferred foods are included as much as possible. Client and family must understand protein intake limitations and how best to meet needs and desires within limitations.
6. Encourage client to eat all meals and supplementary feedings.
Rationale: Client may demonstrate loss of interest in food because of nausea, generalized weakness, and fatigue—which is often first reported symptom and seen in approximately 70% of clients with cirrhosis (Taylor, 2008).
7. Recommend or provide small, frequent meals.
Rationale: Poor tolerance to larger meals may be due to increased intraabdominal pressure or ascites.
8. Limit such high-salt foods as canned soups and vegetables, processed meats, and condiments. Provide salt substitutes if allowed, avoiding those containing ammonia.
Rationale: Salt limitations can help manage fluid complications in cirrhosis, including ascites or tissue edema. Salt substitutes enhance the flavor of food and aid in increasing appetite; ammonia potentiates risk of encephalopathy.
9. Restrict intake of caffeine and gas-producing or spicy and excessively hot or cold foods.
Rationale: Aids in reducing gastric irritation, diarrhea, and abdominal discomfort that may impair oral intake and digestion.
10. Encourage or provide frequent mouth care, especially before meals.
Rationale: Client is prone to sore and bleeding gums and bad taste in mouth, which contributes to anorexia.
Monday, April 18, 2011
Imbalanced Nutrition: Less than Body Requirements | NCP Hepatitis
Nursing diagnosis: Imbalanced Nutrition: Less than Body Requirement related to Insufficient intake to meet metabolic demands—anorexia, nausea, vomiting, Altered absorption and metabolism of ingested foods—reduced peristalsis (visceral reflexes), bile stasis, Increased caloric needs, hypermetabolic state
Possibly evidenced by
Aversion to eating, lack of interest in food; altered taste sensation
Abdominal pain, cramping
Loss of weight, poor muscle tone
Desired Outcomes/Evaluation Criteria—Client Will
Treatment Behavior: Illness or Injury
Initiate behaviors and lifestyle changes to regain or maintain appropriate weight.
Nutritional Status
Demonstrate progressive weight gain toward goal with normalization of laboratory values and no signs of malnutrition.
Nursing intervention with rationale:
1. Monitor dietary intake and calorie count. Provide meals in several small feedings and offer largest meal at breakfast.
Rationale: Large meals are difficult to manage when client is anorexic. Anorexia may also worsen during the day, making intake of food difficult later in the day.
2. Encourage mouth care before meals.
Rationale: Eliminating unpleasant taste may enhance appetite.
3. Recommend eating in upright position.
Rationale: Reduces sensation of abdominal fullness and may enhance intake.
4. Encourage intake of fruit juices, carbonated beverages, and hard candy throughout the day.
Rationale: These supply extra calories and may be more easily digested and tolerated than other fluids and foods.
5. Consult with dietitian or nutritional support team to provide diet according to client’s needs, with fat and protein intake as tolerated.
Rationale: Useful in formulating dietary program to meet individual needs. Fat metabolism varies according to bile production and excretion and may necessitate restriction of fat intake if diarrhea develops. If tolerated, a normal or increased protein intake helps with liver regeneration. Protein restriction may be indicated in severe disease, such as fulminating hepatitis, because the accumulation of the end products of protein metabolism can potentiate hepatic encephalopathy.
6. Monitor serum glucose, as indicated.
Rationale: Hyperglycemia or hypoglycemia may develop, necessitating dietary changes or insulin administration. Fingerstick monitoring may be done by client on a regular schedule to determine therapy needs.
7. Administer medications, as indicated, for example: Antiemetics, such as metoclopramide (Reglan) and trimethobenzamide (Tigan)
Rationale: Given before meals these drugs may reduce nausea and increase food tolerance. Note: Prochlorperazine (Compazine) is contraindicated in hepatic disease.
8. Antiulcer agents and antacids, such as lansoprazole (Prevacid), esomeprazole (Nexium), and magnesium hydroxide/aluminum hydroxide (Maalox, Mylanta)
Rationale: Counteracts gastric acidity, reducing irritation and risk of bleeding.
9. Vitamins, such as B complex, C, and other dietary supplements, as indicated
Rationale: Corrects deficiencies and aids in the healing process.
10. Provide supplemental feedings, enteral or parenteral nutrition if needed.
Rationale: May be necessary to meet nutrient requirements if marked deficits are present and intestinal symptoms are prolonged.
Possibly evidenced by
Aversion to eating, lack of interest in food; altered taste sensation
Abdominal pain, cramping
Loss of weight, poor muscle tone
Desired Outcomes/Evaluation Criteria—Client Will
Treatment Behavior: Illness or Injury
Initiate behaviors and lifestyle changes to regain or maintain appropriate weight.
Nutritional Status
Demonstrate progressive weight gain toward goal with normalization of laboratory values and no signs of malnutrition.
Nursing intervention with rationale:
1. Monitor dietary intake and calorie count. Provide meals in several small feedings and offer largest meal at breakfast.
Rationale: Large meals are difficult to manage when client is anorexic. Anorexia may also worsen during the day, making intake of food difficult later in the day.
2. Encourage mouth care before meals.
Rationale: Eliminating unpleasant taste may enhance appetite.
3. Recommend eating in upright position.
Rationale: Reduces sensation of abdominal fullness and may enhance intake.
4. Encourage intake of fruit juices, carbonated beverages, and hard candy throughout the day.
Rationale: These supply extra calories and may be more easily digested and tolerated than other fluids and foods.
5. Consult with dietitian or nutritional support team to provide diet according to client’s needs, with fat and protein intake as tolerated.
Rationale: Useful in formulating dietary program to meet individual needs. Fat metabolism varies according to bile production and excretion and may necessitate restriction of fat intake if diarrhea develops. If tolerated, a normal or increased protein intake helps with liver regeneration. Protein restriction may be indicated in severe disease, such as fulminating hepatitis, because the accumulation of the end products of protein metabolism can potentiate hepatic encephalopathy.
6. Monitor serum glucose, as indicated.
Rationale: Hyperglycemia or hypoglycemia may develop, necessitating dietary changes or insulin administration. Fingerstick monitoring may be done by client on a regular schedule to determine therapy needs.
7. Administer medications, as indicated, for example: Antiemetics, such as metoclopramide (Reglan) and trimethobenzamide (Tigan)
Rationale: Given before meals these drugs may reduce nausea and increase food tolerance. Note: Prochlorperazine (Compazine) is contraindicated in hepatic disease.
8. Antiulcer agents and antacids, such as lansoprazole (Prevacid), esomeprazole (Nexium), and magnesium hydroxide/aluminum hydroxide (Maalox, Mylanta)
Rationale: Counteracts gastric acidity, reducing irritation and risk of bleeding.
9. Vitamins, such as B complex, C, and other dietary supplements, as indicated
Rationale: Corrects deficiencies and aids in the healing process.
10. Provide supplemental feedings, enteral or parenteral nutrition if needed.
Rationale: May be necessary to meet nutrient requirements if marked deficits are present and intestinal symptoms are prolonged.
Friday, April 1, 2011
Risk for Imbalanced Nutrition: Less than Body Requirements | NCP for Bariatric Surgery
Risk factors may include
Decreased intake, dietary restrictions, early satiety
Increased metabolic rate and healing
Malabsorption of nutrients and impaired absorption of vitamins
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Knowledge: Diet
Identify individual nutritional needs.
Nutritional Status
Display behaviors to maintain adequate nutritional intake.
Demonstrate appropriate weight loss with normalization of laboratory values.
Nursing intervention with rationale:
1. Establish hourly intake schedule. Measure and provide food and fluids in amount specified.
Rationale: After gastric restriction procedures, stomach capacity is reduced to approximately 30 to 50 mL, necessitating frequent, small feedings. Ultimately, management of optimal nutrition depends on reducing the amount of food passing through the gastrointestinal (GI) system at one time.
2. Instruct in how to eat slowly. Take small bites, using a baby spoon. Chew food thoroughly. Take 3 to 60 minutes to eat meal, then refrain from eating until next scheduled mealtime.
Rationale: Increases satiety and reduces risk of overeating.
3. Avoid taking fluids with meals and for 30 minutes before or after meals. Encourage almost constant sipping of fluids between scheduled eating times.
Rationale: Although fluids are a necessary part of the client’s intake, the stomach is too small to hold food and fluids at the same time.
4. Avoid high-calorie fluids—milkshakes, sodas, and alcoholic beverages.
Rationale: These can sabotage weight loss.
5. Emphasize importance of recognizing satiety and stopping intake.
Rationale: Overeating may cause nausea and vomiting, as well as having the potential to damage surgical anastomosis.
6. Require that client sit up to drink and eat.
Rationale: Reduces possibility of aspiration.
7. Determine foods that are gas forming and eliminate them from diet.
Rationale: May cause nausea and bloating, interfering with digestion and causing client to restrict nutritional intake.
8. Discuss food preferences with client and include those foods in puréed diet when possible.
Rationale: May enhance intake and promote sense of participation and control.
9. Weigh on regular schedule.
Rationale: Monitors losses and aids in assessing nutritional needs and effectiveness of therapy.
10. Refer to dietitian or multidisciplinary team.
Rationale: Provides assistance in planning a diet that meets client’s nutritional needs as well as offering individualized treatment and support. Note: Because quantity is strictly limited, foods should be nutrient dense, low in fat and sugars, and high in protein (Beauchamp-Johnson, 2006).
Decreased intake, dietary restrictions, early satiety
Increased metabolic rate and healing
Malabsorption of nutrients and impaired absorption of vitamins
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Knowledge: Diet
Identify individual nutritional needs.
Nutritional Status
Display behaviors to maintain adequate nutritional intake.
Demonstrate appropriate weight loss with normalization of laboratory values.
Nursing intervention with rationale:
1. Establish hourly intake schedule. Measure and provide food and fluids in amount specified.
Rationale: After gastric restriction procedures, stomach capacity is reduced to approximately 30 to 50 mL, necessitating frequent, small feedings. Ultimately, management of optimal nutrition depends on reducing the amount of food passing through the gastrointestinal (GI) system at one time.
2. Instruct in how to eat slowly. Take small bites, using a baby spoon. Chew food thoroughly. Take 3 to 60 minutes to eat meal, then refrain from eating until next scheduled mealtime.
Rationale: Increases satiety and reduces risk of overeating.
3. Avoid taking fluids with meals and for 30 minutes before or after meals. Encourage almost constant sipping of fluids between scheduled eating times.
Rationale: Although fluids are a necessary part of the client’s intake, the stomach is too small to hold food and fluids at the same time.
4. Avoid high-calorie fluids—milkshakes, sodas, and alcoholic beverages.
Rationale: These can sabotage weight loss.
5. Emphasize importance of recognizing satiety and stopping intake.
Rationale: Overeating may cause nausea and vomiting, as well as having the potential to damage surgical anastomosis.
6. Require that client sit up to drink and eat.
Rationale: Reduces possibility of aspiration.
7. Determine foods that are gas forming and eliminate them from diet.
Rationale: May cause nausea and bloating, interfering with digestion and causing client to restrict nutritional intake.
8. Discuss food preferences with client and include those foods in puréed diet when possible.
Rationale: May enhance intake and promote sense of participation and control.
9. Weigh on regular schedule.
Rationale: Monitors losses and aids in assessing nutritional needs and effectiveness of therapy.
10. Refer to dietitian or multidisciplinary team.
Rationale: Provides assistance in planning a diet that meets client’s nutritional needs as well as offering individualized treatment and support. Note: Because quantity is strictly limited, foods should be nutrient dense, low in fat and sugars, and high in protein (Beauchamp-Johnson, 2006).
Monday, March 21, 2011
Imbalanced Nutrition: Less than Body Requirements | NCP Anorexia/Bulimia
Nursing diagnosis: imbalanced Nutrition: Less than Body Requirements related to Inadequate food intake, self-induced vomiting, Chronic, excessive laxative use
Possibly evidenced by
Body weight 15% or more below expected, or may be within normal range or overweight (bulimia)
Pale conjunctiva and mucous membranes, poor skin turgor and muscle tone, edema
Excessive loss of hair, increased growth of hair on body (lanugo)
Amenorrhea
Hypothermia
Bradycardia, cardiac irregularities, hypotension
Desired Outcomes/Evaluation Criteria—Client Will
Knowledge: Diet
Verbalize understanding of nutritional needs.
Nutritional Status
Establish a dietary pattern with caloric intake adequate to regain or maintain appropriate weight.
Demonstrate weight gain toward individually expected range.
Nursing intervention with rationale:
1. Establish a minimum weight goal and daily nutritional requirements.
Rationale: Provides comparative baseline for effectiveness of therapy. Note: Malnutrition is a mood-altering condition, leading to depression and affecting cognitive function and decision making. Improved nutritional status enhances thinking ability, allowing initiation of psychological work.
2. Contract with client regarding commitment to therapeutic program and meeting specific dietary needs and goals.
Rationale: When client agrees to a contract, individual success is enhanced.
3. Use a consistent approach. Sit with client while eating; present and remove food without persuasion or comment. Promote pleasant environment and record intake.
Rationale: Client detects urgency and may react to pressure. Any comment that might be seen as coercion provides focus on food. When staff responds in a consistent manner, client can begin to trust staff responses. The single area in which client has exercised power and control is food and eating, and she or he may experience guilt or rebellion if forced to eat. Structuring meals and decreasing discussions about food will decrease power struggles with client and avoid manipulative games.
4. Provide small, frequent, and nutritionally dense meals and supplemental snacks, as appropriate.
Rationale: Gastric dilation may occur if refeeding is too rapid following a period of starvation dieting. Client may feel bloated for weeks while body adjusts to increased food intake. Note: Client at risk for developing refeeding syndrome.
5. Make selective menu available, and allow client to control choices as much as possible.
Rationale: Client who gains confidence in self and feels in control of environment is more likely to eat preferred foods.
6. Be alert to choices of low-calorie foods and beverages, hoarding food, and disposing of food in various places, such as pockets or wastebaskets.
Rationale: Client will try to avoid taking in what is viewed as excessive calories and may go to great lengths to avoid eating.
7. Maintain a regular weighing schedule, such as Monday and Friday before breakfast in same attire, and graph results.
Rationale: Provides accurate ongoing record of weight loss or gain. Also diminishes obsessing about changes in weight.
8. Weigh with back to scale, depending on program protocols.
Rationale: Although some programs prefer that client does not see the results of the weighing, this can force the issue of trust in client who usually does not trust others.
9. Avoid room checks and other control devices whenever possible.
Rationale: External control reinforces feelings of powerlessness and therefore is usually not helpful.
10. Provide one-to-one supervision and have client with bulimia remain in the day room area or in sight with no bathroom privileges for a specified period, such as 2 to 3 hours, following eating if contracting is unsuccessful.
Rationale: Prevents vomiting during or immediately after eating. Client may desire food and eating, but use a binge-purge syndrome to control weight. Note: Some clients purge for the first time in response to establishment of a weight-gain program.
Possibly evidenced by
Body weight 15% or more below expected, or may be within normal range or overweight (bulimia)
Pale conjunctiva and mucous membranes, poor skin turgor and muscle tone, edema
Excessive loss of hair, increased growth of hair on body (lanugo)
Amenorrhea
Hypothermia
Bradycardia, cardiac irregularities, hypotension
Desired Outcomes/Evaluation Criteria—Client Will
Knowledge: Diet
Verbalize understanding of nutritional needs.
Nutritional Status
Establish a dietary pattern with caloric intake adequate to regain or maintain appropriate weight.
Demonstrate weight gain toward individually expected range.
Nursing intervention with rationale:
1. Establish a minimum weight goal and daily nutritional requirements.
Rationale: Provides comparative baseline for effectiveness of therapy. Note: Malnutrition is a mood-altering condition, leading to depression and affecting cognitive function and decision making. Improved nutritional status enhances thinking ability, allowing initiation of psychological work.
2. Contract with client regarding commitment to therapeutic program and meeting specific dietary needs and goals.
Rationale: When client agrees to a contract, individual success is enhanced.
3. Use a consistent approach. Sit with client while eating; present and remove food without persuasion or comment. Promote pleasant environment and record intake.
Rationale: Client detects urgency and may react to pressure. Any comment that might be seen as coercion provides focus on food. When staff responds in a consistent manner, client can begin to trust staff responses. The single area in which client has exercised power and control is food and eating, and she or he may experience guilt or rebellion if forced to eat. Structuring meals and decreasing discussions about food will decrease power struggles with client and avoid manipulative games.
4. Provide small, frequent, and nutritionally dense meals and supplemental snacks, as appropriate.
Rationale: Gastric dilation may occur if refeeding is too rapid following a period of starvation dieting. Client may feel bloated for weeks while body adjusts to increased food intake. Note: Client at risk for developing refeeding syndrome.
5. Make selective menu available, and allow client to control choices as much as possible.
Rationale: Client who gains confidence in self and feels in control of environment is more likely to eat preferred foods.
6. Be alert to choices of low-calorie foods and beverages, hoarding food, and disposing of food in various places, such as pockets or wastebaskets.
Rationale: Client will try to avoid taking in what is viewed as excessive calories and may go to great lengths to avoid eating.
7. Maintain a regular weighing schedule, such as Monday and Friday before breakfast in same attire, and graph results.
Rationale: Provides accurate ongoing record of weight loss or gain. Also diminishes obsessing about changes in weight.
8. Weigh with back to scale, depending on program protocols.
Rationale: Although some programs prefer that client does not see the results of the weighing, this can force the issue of trust in client who usually does not trust others.
9. Avoid room checks and other control devices whenever possible.
Rationale: External control reinforces feelings of powerlessness and therefore is usually not helpful.
10. Provide one-to-one supervision and have client with bulimia remain in the day room area or in sight with no bathroom privileges for a specified period, such as 2 to 3 hours, following eating if contracting is unsuccessful.
Rationale: Prevents vomiting during or immediately after eating. Client may desire food and eating, but use a binge-purge syndrome to control weight. Note: Some clients purge for the first time in response to establishment of a weight-gain program.
Saturday, March 19, 2011
Risk for Imbalanced Nutrition: Less than Body Requirements | NCP for Cholecystitis
Risk factors may include
Self-imposed or prescribed dietary restrictions, nausea and vomiting, dyspepsia, pain
Loss of nutrients; impaired fat digestion due to obstruction of bile flow
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Nutritional Status
Report relief of nausea and vomiting.
Demonstrate progression toward desired weight gain or maintain weight as individually appropriate.
Nursing intervention with rationale:
1. Estimate or calculate caloric intake. Keep comments about appetite to a minimum.
Rationale: Identifies nutritional deficiencies and needs. Focusing on problem creates a negative atmosphere and may interfere with intake.
2. Weigh, as indicated.
Rationale: Monitors effectiveness of dietary plan.
3. Consult with client about likes and dislikes, foods that cause distress, and preferred meal schedule.
Rationale: Involving client in planning enables client to have a sense of control and encourages eating.
4. Provide a pleasant atmosphere at mealtime; remove noxious stimuli.
Rationale: Useful in promoting appetite and reducing nausea.
5. Provide oral hygiene before meals.
Rationale: A clean mouth enhances appetite.
6. Offer effervescent drinks with meals if tolerated.
Rationale: May lessen nausea and relieve gas. Note: May be contraindicated if beverage causes gas formation with subsequent gastric discomfort.
7. Assess for abdominal distention, frequent belching, guarding, and reluctance to move.
Rationale: Nonverbal signs of discomfort associated with impaired digestion, gas pain.
8. Ambulate and increase activity, as tolerated.
Rationale: Helpful in expulsion of flatus and reduction of abdominal distention. Contributes to overall recovery and sense of well-being and decreases possibility of secondary problems related to immobility such as pneumonia and thrombophlebitis.
9. Consult with dietitian and nutritional support team, as indicated.
Rationale: Useful in establishing individual nutritional needs and most appropriate route.
10. Begin low-fat liquid diet after NG tube is removed.
Rationale: Limiting fat content reduces stimulation of gallbladder and pain associated with incomplete fat digestion and is helpful in preventing recurrence.
Self-imposed or prescribed dietary restrictions, nausea and vomiting, dyspepsia, pain
Loss of nutrients; impaired fat digestion due to obstruction of bile flow
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Nutritional Status
Report relief of nausea and vomiting.
Demonstrate progression toward desired weight gain or maintain weight as individually appropriate.
Nursing intervention with rationale:
1. Estimate or calculate caloric intake. Keep comments about appetite to a minimum.
Rationale: Identifies nutritional deficiencies and needs. Focusing on problem creates a negative atmosphere and may interfere with intake.
2. Weigh, as indicated.
Rationale: Monitors effectiveness of dietary plan.
3. Consult with client about likes and dislikes, foods that cause distress, and preferred meal schedule.
Rationale: Involving client in planning enables client to have a sense of control and encourages eating.
4. Provide a pleasant atmosphere at mealtime; remove noxious stimuli.
Rationale: Useful in promoting appetite and reducing nausea.
5. Provide oral hygiene before meals.
Rationale: A clean mouth enhances appetite.
6. Offer effervescent drinks with meals if tolerated.
Rationale: May lessen nausea and relieve gas. Note: May be contraindicated if beverage causes gas formation with subsequent gastric discomfort.
7. Assess for abdominal distention, frequent belching, guarding, and reluctance to move.
Rationale: Nonverbal signs of discomfort associated with impaired digestion, gas pain.
8. Ambulate and increase activity, as tolerated.
Rationale: Helpful in expulsion of flatus and reduction of abdominal distention. Contributes to overall recovery and sense of well-being and decreases possibility of secondary problems related to immobility such as pneumonia and thrombophlebitis.
9. Consult with dietitian and nutritional support team, as indicated.
Rationale: Useful in establishing individual nutritional needs and most appropriate route.
10. Begin low-fat liquid diet after NG tube is removed.
Rationale: Limiting fat content reduces stimulation of gallbladder and pain associated with incomplete fat digestion and is helpful in preventing recurrence.
Monday, March 7, 2011
Risk for Imbalanced Nutrition: Less than Body Requirements
Nursing diagnosis: risk for Imbalanced Nutrition: Less than Body Requirements
Risk factors may include
Prolonged anorexia, altered intake preoperatively
Hypermetabolic state—preoperative inflammatory disease; healing process
Presence of diarrhea; altered absorption
Restriction of bulk and residue-containing foods
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Nutritional Status
Maintain weight or demonstrate progressive weight gain toward goal with normalization of laboratory values and be free of signs of malnutrition.
Plan diet to meet nutritional needs and limit gastrointestinal (GI) disturbances.
Nursing intervention with rationale:
1. Obtain a thorough nutritional assessment.
Rationale: Identifies deficiencies and needs to aid in choice of interventions.
2. Auscultate bowel sounds.
Rationale: Return of intestinal function indicates readiness to resume oral intake.
3. Resume solid foods slowly.
Rationale: Reduces incidence of abdominal cramps and nausea.
4. Identify odor-causing foods, for instance, cabbage, fish, and beans, and temporarily restrict from diet. Gradually reintroduce one food at a time.
Rationale: Sensitivity to certain foods is not uncommon following intestinal surgery. Client can experiment with food several times before determining whether it is creating a problem.
5. Recommend client increase use of yogurt, buttermilk, and acidophilus preparations.
Rationale: May help prevent gas and decrease odor formation.
6. Suggest client with ileostomy limit prunes, dates, stewed apricots, strawberries, grapes, bananas, cabbage family, and beans, and avoid foods high in cellulose, such as peanuts.
Rationale: These products increase ileal effluent. Digestion of cellulose requires colonic bacteria that are no longer present.
7. Discuss mechanics of swallowed air as a factor in the formation of flatus and some ways client can exercise control. Discuss use of a pouch with a filter to help with the management of gas.
Rationale: Drinking through a straw, snoring, anxiety, smoking, ill-fitting dentures, and gulping down food increase the production of flatus. Too much flatus not only necessitates frequent emptying, but also can cause leakage from too much pressure within the pouch.
8. Consult with dietitian and nutrition specialist.
Rationale: Helpful in assessing client’s nutritional needs in light of changes in digestion and intestinal function, including absorption of vitamins and minerals.
9. Advance diet from liquids to low-residue food when oral intake is resumed.
Rationale: Low-residue diet may be maintained during first 6 to 8 weeks to provide adequate time for intestinal healing.
10. Administer enteral or parenteral feedings when indicated.
Rationale: In the presence of severe debilitation or intolerance of oral intake, parenteral or enteral feedings may be given to supply needed components for healing and prevention of catabolic state.
Risk factors may include
Prolonged anorexia, altered intake preoperatively
Hypermetabolic state—preoperative inflammatory disease; healing process
Presence of diarrhea; altered absorption
Restriction of bulk and residue-containing foods
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Nutritional Status
Maintain weight or demonstrate progressive weight gain toward goal with normalization of laboratory values and be free of signs of malnutrition.
Plan diet to meet nutritional needs and limit gastrointestinal (GI) disturbances.
Nursing intervention with rationale:
1. Obtain a thorough nutritional assessment.
Rationale: Identifies deficiencies and needs to aid in choice of interventions.
2. Auscultate bowel sounds.
Rationale: Return of intestinal function indicates readiness to resume oral intake.
3. Resume solid foods slowly.
Rationale: Reduces incidence of abdominal cramps and nausea.
4. Identify odor-causing foods, for instance, cabbage, fish, and beans, and temporarily restrict from diet. Gradually reintroduce one food at a time.
Rationale: Sensitivity to certain foods is not uncommon following intestinal surgery. Client can experiment with food several times before determining whether it is creating a problem.
5. Recommend client increase use of yogurt, buttermilk, and acidophilus preparations.
Rationale: May help prevent gas and decrease odor formation.
6. Suggest client with ileostomy limit prunes, dates, stewed apricots, strawberries, grapes, bananas, cabbage family, and beans, and avoid foods high in cellulose, such as peanuts.
Rationale: These products increase ileal effluent. Digestion of cellulose requires colonic bacteria that are no longer present.
7. Discuss mechanics of swallowed air as a factor in the formation of flatus and some ways client can exercise control. Discuss use of a pouch with a filter to help with the management of gas.
Rationale: Drinking through a straw, snoring, anxiety, smoking, ill-fitting dentures, and gulping down food increase the production of flatus. Too much flatus not only necessitates frequent emptying, but also can cause leakage from too much pressure within the pouch.
8. Consult with dietitian and nutrition specialist.
Rationale: Helpful in assessing client’s nutritional needs in light of changes in digestion and intestinal function, including absorption of vitamins and minerals.
9. Advance diet from liquids to low-residue food when oral intake is resumed.
Rationale: Low-residue diet may be maintained during first 6 to 8 weeks to provide adequate time for intestinal healing.
10. Administer enteral or parenteral feedings when indicated.
Rationale: In the presence of severe debilitation or intolerance of oral intake, parenteral or enteral feedings may be given to supply needed components for healing and prevention of catabolic state.
Monday, February 28, 2011
imbalanced Nutrition: Less than Body Requirements | Nursing Care Plan for Inflammatory Bowel Disease
Nursing diagnosis: imbalanced Nutrition: Less than Body Requirements related to
Altered absorption of nutrients
Hypermetabolic state
Medically restricted intake; fear that eating may cause diarrhea
Possibly evidenced by
Weight loss, decreased subcutaneous fat and muscle mass, poor muscle tone
Hyperactive bowel sounds, steatorrhea
Pale conjunctiva and mucous membranes
Aversion to eating
Desired Outcomes/Evaluation Criteria—Client Will
Nutritional Status
Demonstrate stable weight or progressive gain toward goal with normalization of laboratory values and absence of signs of malnutrition.
Nursing intervention with rationale:
1. Assess weight, age, body mass, strength, and activity and rest levels. Ascertain stage of disease process and its effects on client’s nutritional status.
Rationale: Provides comparative baseline.
2. Inspect oral mucosa.
Rationale: May reveal ulcerations and/or provide information about the integrity of the entire GI tract, affecting ability to eat and absorb nutrients.
3. Evaluate client’s appetite.
Rationale: Appetite may be suppressed because of altered taste, early satiety, meal-related cramping, diarrhea, or a combination of these factors.
4. Weigh frequently.
Rationale: Provides information about dietary needs and effectiveness of therapy.
5. Encourage bedrest or limited activity during acute phase of illness.
Rationale: Decreasing metabolic needs aids in preventing caloric depletion and conserves energy.
6. Recommend rest before meals.
Rationale: Quiets peristalsis and increases available energy for eating.
7. Provide oral hygiene.
Rationale: A clean mouth can enhance the taste of food.
8. Serve foods in well-ventilated, pleasant surroundings, with unhurried atmosphere and congenial company.
Rationale: Pleasant environment aids in reducing stress and is more conducive to eating.
9. Avoid or limit foods that might cause or exacerbate abdominal cramping and flatulence—milk products, foods high in fiber or fat, alcohol, caffeinated beverages, chocolate, peppermint, tomatoes, and orange juice.
Rationale: Individual tolerance varies, depending on stage of disease and area of bowel affected.
10. Provide nutritional support, for example: Enteral feedings, such as Ultra Clear Plus via nasogastric (NG) tube, percutaneous endoscopic gastrostomy (PEG), or J-tube
Rationale: Many clinical studies have shown early enteral feeding is beneficial in reducing the effects of malabsorption and providing essential nutrients. Although elemental enteral solutions cannot provide all needed nutrients, they can prevent gut atrophy.
Saturday, February 26, 2011
Nursing Care Plan (NCP) Gastrectomy | Risk for Imbalanced Nutrition: Less than Body Requirements
Nursing diagnosis: risk for imbalanced Nutrition: Less than Body Requirements
Risk factors may include
Restriction of fluids and food
Change in digestive process, absorption of nutrients
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Nutritional Status
Maintain stable weight and demonstrate progressive weight gain toward goal with normalization of laboratory values.
Be free of signs of malnutrition.
Nursing intervention with rationale:
1. Maintain patency of NG, OG, or NI tube when used. Be aware of feeding tube placement—enterostomal or jejunostomal. Notify physician if tube becomes dislodged.
Rationale: Intestinal tubes are inserted to provide rest for gastrointestinal (GI) tract during acute postoperative phase until return of normal GI function. These are attached to suction. Feeding tubes may be inserted at time of surgery or later and are used to provide enteral feedings once gut is functional. Note: Although several methods have been used to identify tube placement at the bedside, such as aspiration of gastric contents, measurement of trypsin, pH, and pepsin levels, abdominal radiographs may be necessary to confirm location of tube, and the physician/surgeon may need to reposition the tube endoscopically to prevent injury to the
operative area.
2. Note character and amount of gastric drainage.
Rationale: Drainage may be bloody for first few hours and then should clear or turn greenish gold. Continued or recurrent bleeding suggest complications and should be reported to physician.
3. Caution client to limit the intake of ice chips.
Rationale: Excessive intake of ice produces nausea and can wash out electrolytes via the NG tube.
4. Provide oral hygiene on a regular, frequent basis, including petroleum jelly for lips.
Rationale: Prevents discomfort of dry mouth and cracked lips caused by fluid restriction and the NG tube.
5. Auscultate for resumption of bowel sounds and note passage of flatus.
Rationale: Peristalsis can be expected to return about the third postoperative day, signaling readiness to resume oral intake.
6. Monitor tolerance to fluid and food intake when resumed, noting abdominal distention, reports of increased pain or cramping, and nausea and vomiting.
Rationale: Complications such as paralytic ileus, obstruction, delayed gastric emptying, or gastric dilation, may occur. Even if the above complications do not occur, “dumping syndrome” is a fairly common aftereffect of stomach surgery. Symptoms include bloating, nausea, weakness, sweating, and rapid heartbeat 30 to 60 minutes after a meal.
7. Note admission weight and compare with subsequent readings.
Rationale: Provides information about adequacy of dietary intake and determination of nutritional needs.
8. Collaborate with nutritional team and dietitian, as indicated.
Rationale: Aids in determining number of calories and types of nutrients for meeting client’s nutritional needs.
9. Administer intravenous (IV) fluids, parenteral or enteral nutrition, as indicated.
Rationale: Meets fluid and nutritional needs until oral intake can be resumed. Note: Early enteral feedings have been found to stimulate gut immunological function and can assist in maintaining gut structure and function. TPN is usually reserved for clients who are critically ill at the time of
surgery or those with total gastrectomy.
10. Monitor laboratory studies: hemoglobin/hematocrit (Hgb/Hct), electrolytes, and total protein and prealbumin.
Rationale: Indicators of fluid and nutritional needs and effectiveness of therapy. Detects developing complications.
Sunday, January 9, 2011
Risk for Imbalanced Nutrition: Less than Body Requirements | Nursing Care Plan for Craniocerebral Trauma
Nursing diagnosis: Risk for Imbalanced Nutrition: Less than Body Requirements
Altered ability to ingest nutrients—decreased LOC
Weakness of muscles required for chewing, swallowing
Hypermetabolic state
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Nutritional Status
Demonstrate maintenance of desired weight or progressive weight gain toward goal.
Experience no signs of malnutrition, with laboratory values within normal range.
Nursing intervention with rationale:
1. Assess ability to chew, swallow, cough, and handle secretions.
Rationale: These factors determine choice of feeding options because client must be protected from aspiration.
2. Auscultate bowel sounds, noting decreased or absent or hyperactive sounds.
Rationale: Gastrointestinal (GI) functioning is usually preserved in braininjured clients, so bowel sounds help in determining response to feeding or development of complications, such as ileus.
3. Weigh, as indicated.
Rationale: Evaluates effectiveness or need for changes in nutritional therapy.
4. Provide for feeding safety, such as elevate head of bed while eating or during tube feeding.
Rationale: Reduces risk of regurgitation and aspiration.
5. Divide feedings into small amounts and give frequently.
Rationale: Enhances digestion and client’s tolerance of nutrients and can improve client cooperation in eating.
6. Promote pleasant, relaxing environment, including socialization during meals. Encourage SO to bring in food that client enjoys.
Rationale: Although the recovering client may require assistance with feeding and use of assistive devices, mealtime socialization with SO or friends can improve intake and normalize the life function of eating.
7. Check stools, gastric aspirant, and vomitus for blood.
Rationale: Acute or subacute bleeding may occur (Cushing’s ulcer), requiring intervention and alternative method of providing nutrition.
8. Consult with dietitian or nutritional support team.
Rationale: Helps determine the client’s requirements for energy and to provide needed nutrients. Careful monitoring of nutrition indicators, such as weight and blood tests, are necessary to prevent problems associated with malnutrition—muscle wasting, pressure sores and decubitus ulcers, renal failure, atelectasis, and pneumonia.
9. Monitor laboratory studies, for example, prealbumin or albumin, transferrin, amino acid profile, iron, blood urea nitrogen (BUN), nitrogen balance studies, glucose, aspartate aminotransferase (AST) and alanine aminotransferase (ALT), and electrolytes.
Rationale: Identifies nutritional deficiencies, organ function, and response to nutritional therapy.
10. Administer feedings by appropriate means—IV, tube feeding, or oral feedings with soft foods and thick liquids.
Rationale: Choice of route depends on client needs and capabilities. Tube feedings (nasogastric, jejunostomy) may be required initially, or parenteral route may be indicated in presence of gastric or intestinal pathology. If client is able to swallow, soft foods or semiliquid foods may be more easily managed without aspiration.
Altered ability to ingest nutrients—decreased LOC
Weakness of muscles required for chewing, swallowing
Hypermetabolic state
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Nutritional Status
Demonstrate maintenance of desired weight or progressive weight gain toward goal.
Experience no signs of malnutrition, with laboratory values within normal range.
Nursing intervention with rationale:
1. Assess ability to chew, swallow, cough, and handle secretions.
Rationale: These factors determine choice of feeding options because client must be protected from aspiration.
2. Auscultate bowel sounds, noting decreased or absent or hyperactive sounds.
Rationale: Gastrointestinal (GI) functioning is usually preserved in braininjured clients, so bowel sounds help in determining response to feeding or development of complications, such as ileus.
3. Weigh, as indicated.
Rationale: Evaluates effectiveness or need for changes in nutritional therapy.
4. Provide for feeding safety, such as elevate head of bed while eating or during tube feeding.
Rationale: Reduces risk of regurgitation and aspiration.
5. Divide feedings into small amounts and give frequently.
Rationale: Enhances digestion and client’s tolerance of nutrients and can improve client cooperation in eating.
6. Promote pleasant, relaxing environment, including socialization during meals. Encourage SO to bring in food that client enjoys.
Rationale: Although the recovering client may require assistance with feeding and use of assistive devices, mealtime socialization with SO or friends can improve intake and normalize the life function of eating.
7. Check stools, gastric aspirant, and vomitus for blood.
Rationale: Acute or subacute bleeding may occur (Cushing’s ulcer), requiring intervention and alternative method of providing nutrition.
8. Consult with dietitian or nutritional support team.
Rationale: Helps determine the client’s requirements for energy and to provide needed nutrients. Careful monitoring of nutrition indicators, such as weight and blood tests, are necessary to prevent problems associated with malnutrition—muscle wasting, pressure sores and decubitus ulcers, renal failure, atelectasis, and pneumonia.
9. Monitor laboratory studies, for example, prealbumin or albumin, transferrin, amino acid profile, iron, blood urea nitrogen (BUN), nitrogen balance studies, glucose, aspartate aminotransferase (AST) and alanine aminotransferase (ALT), and electrolytes.
Rationale: Identifies nutritional deficiencies, organ function, and response to nutritional therapy.
10. Administer feedings by appropriate means—IV, tube feeding, or oral feedings with soft foods and thick liquids.
Rationale: Choice of route depends on client needs and capabilities. Tube feedings (nasogastric, jejunostomy) may be required initially, or parenteral route may be indicated in presence of gastric or intestinal pathology. If client is able to swallow, soft foods or semiliquid foods may be more easily managed without aspiration.
Saturday, December 25, 2010
Imbalanced Nutrition: Less than Body Requirements | Nursing Care Plan for Tuberculosis
Nursing diagnosis: imbalanced Nutrition: Less than Body Requirements related to fatigue; frequent cough and sputum production; dyspnea; anorexia; insufficient financial resources
Possibly evidenced by
Weight 10% to 20% below ideal for frame and height
Reported lack of interest in food, altered taste sensation
Poor muscle tone
Desired Outcomes/Evaluation Criteria—Client Will
Nutritional Status
Demonstrate progressive weight gain toward goal with normalization of laboratory values and be free of signs of malnutrition.
Initiate behaviors or lifestyle changes to regain and to maintain appropriate weight.
Nursing intervention with rationale:
1. Document client’s nutritional status on admission, noting skin turgor, current weight and degree of weight loss, integrity of oral mucosa, ability to swallow, presence of bowel tones,
and history of nausea, vomiting, or diarrhea.
Rationale: Useful in defining extent of problem and appropriate choice of interventions.
2. Ascertain client’s usual dietary pattern and likes and dislikes.
Rationale: Helps to identify specific needs or strengths. Consideration of individual preferences may improve dietary intake.
3. Monitor intake and ouput (I&O) and weight periodically.
Rationale: Useful in measuring effectiveness of nutritional and fluid support.
4. Investigate anorexia, nausea, and vomiting. Note possible correlation to medications. Monitor frequency, volume, and consistency of stools.
Rationale: Affects dietary choices and can identify areas for problem-solving to enhance intake of nutrients.
5. Encourage and provide for frequent rest periods.
Rationale: Helps conserve energy, especially when metabolic requirements are increased by fever.
6. Provide oral care before and after respiratory treatments.
Rationale: Reduces bad taste left from sputum or medications used for respiratory treatments that can stimulate the vomiting center.
7. Encourage small, frequent meals with foods high in protein and carbohydrates.
Rationale: Maximizes nutrient intake without undue energy expenditure from eating large meals.
8. Encourage SO to bring foods from home and to share meals with client unless contraindicated.
Rationale: Creates a more normal social environment during mealtime and helps meet personal and cultural preferences.
9. Refer to dietitian for adjustments in dietary composition.
Rationale: Provides assistance in planning a diet with nutrients adequate to meet client’s metabolic requirements, dietary preferences, and financial resources postdischarge.
10. Consult with respiratory therapy to schedule treatments 1 to 2 hours before or after meals.
Rationale: May help reduce the incidence of nausea and vomiting associated with medications or the effects of respiratory treatments on a full stomach.
Wednesday, December 15, 2010
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.
Saturday, November 27, 2010
Nursing Diagnosis for Pneumonia | Imbalanced Nutrition: Less than Body Requirements
Nursing diagnosis: Imbalanced Nutrition: Less than Body Requirements
Risk factors may include
Increased metabolic needs secondary to fever and infectious process
Anorexia associated with bacterial toxins, the odor and taste of sputum, and certain aerosol treatments
Abdominal distention and gas associated with swallowing air during dyspneic episodes
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Nutritional Status
Demonstrate increased appetite.
Maintain or regain desired body weight.
Nursing intervention with rationale:
1. Identify factors that are contributing to inability to eat, such as severe dyspnea, pain, nausea and vomiting, copious sputum, or respiratory treatments.
Rationale: Choice of interventions depends on the underlying cause of the problem.
2. Provide covered container for sputum and replace at frequent intervals. Assist with and encourage oral hygiene after emesis, after aerosol and postural drainage treatments, and before meals.
Rationale: Eliminates noxious sights, tastes, and smells from the client’s environment and can reduce nausea.
3. Schedule respiratory treatments at least 1 hour before meals.
Rationale: Reduces effects of nausea associated with these treatments.
4. Auscultate for bowel sounds. Observe and palpate for abdominal distention.
Rationale: Bowel sounds may be diminished or absent if the infectious process is severe or prolonged. Abdominal distention may occur because of air swallowing or reflect the influence of bacterial toxins on the gastrointestinal (GI) tract.
5. Provide small, frequent meals, including dry foods, such as toast or crackers, and foods that are appealing to client.
Rationale: These measures may enhance intake even though appetite may be slow to return.
6. Evaluate general nutritional state. Obtain baseline weight.
Rationale: Lifestyle, financial, and socioeconomic conditions prior to present illness condition can contribute to malnutrition. Client may present with hypermetabolic state and lowered
resistance to infection, which can exacerbate malnutrition and delay response to therapy.
7. Weigh regularly and graph results.
Rationale: Monitors effectiveness of nutritional therapy.
8. Assist in treatment of underlying condition(s).
Rationale: May promote healing and strengthen immune system, improve appetite, and enhance general well-being.
9. Consult dietitian and nutritional team.
Rationale: To develop dietary plan individualized to client’s specific needs and challenges.
Wednesday, November 24, 2010
Nursing Diagnosis for COPD and Asthma | Imbalanced Nutrition: Less than Body Requirements
Nursing diagnosis: imbalanced Nutrition: Less than Body Requirements related to dyspnea, sputum production; medication side effects; anorexia, nausea or vomiting; fatigue
Possibly evidenced by
Weight loss, loss of muscle mass, poor muscle tone
Reported altered taste sensation, aversion to eating, lack of interest in food
Desired Outcomes/Evaluation Criteria—Client Will
Nutritional Status
Display progressive weight gain toward goal as appropriate.
Demonstrate behaviors and lifestyle changes to regain and maintain appropriate weight.
Nursing intervention with rationale:
1. Assess dietary habits, recent food intake. Note degree of difficulty with eating. Evaluate weight and body size or mass.
Rationale: Client in acute respiratory distress is often anorectic because of dyspnea, sputum production, and medication effects. In addition, many COPD clients habitually eat poorly even though respiratory insufficiency creates a hypermetabolic state with increased caloric needs. As a result, client often is admitted with some degree of malnutrition. People who have emphysema are often thin, with wasted musculature.
2. Auscultate bowel sounds.
Rationale: Diminished or hypoactive bowel sounds may reflect decreased gastric motility and constipation (common complication) related to limited fluid intake, poor food choices, decreased activity, and hypoxemia.
3. Give frequent oral care, remove expectorated secretions promptly, and provide specific container for disposal of secretions and tissues.
Rationale: Noxious tastes, smells, and sights are prime deterrents to appetite and can produce nausea and vomiting with increased respiratory difficulty.
4. Encourage a rest period of 1 hour before and after meals. Provide frequent small feedings.
Rationale: Helps reduce fatigue during mealtime, and provides opportunity to increase total caloric intake.
5. Avoid gas-producing foods and carbonated beverages.
Rationale: Can produce abdominal distention, which hampers abdominal breathing and diaphragmatic movement and can increase dyspnea.
6. Avoid very hot or very cold foods.
Rationale: Extremes in temperature can precipitate or aggravate coughing spasms.
7. Weigh, as indicated.
Rationale: Useful in determining caloric needs, setting weight goal, and evaluating adequacy of nutritional plan. Note: Weight loss may continue initially despite adequate intake, as edema is resolving.
8. Consult dietitian or nutritional support team to provide easily digested, nutritionally balanced meals by mouth, supplemental or tube feedings, and parenteral nutrition.
Rationale: Method of feeding and caloric requirements are based on individual situation and specific needs to provide maximal nutrients with minimal client effort and energy expenditure.
9. Review serum albumin or prealbumin, transferrin, amino acid profile, iron, nitrogen balance studies, glucose, liver function studies, and electrolyte laboratory values as ordered.
Rationale: Determines deficits and monitors effectiveness of nutritional therapy.
10. Administer supplemental oxygen during meals, as indicated.
Rationale: Decreases dyspnea and increases energy for eating, enhancing intake.
Possibly evidenced by
Weight loss, loss of muscle mass, poor muscle tone
Reported altered taste sensation, aversion to eating, lack of interest in food
Desired Outcomes/Evaluation Criteria—Client Will
Nutritional Status
Display progressive weight gain toward goal as appropriate.
Demonstrate behaviors and lifestyle changes to regain and maintain appropriate weight.
Nursing intervention with rationale:
1. Assess dietary habits, recent food intake. Note degree of difficulty with eating. Evaluate weight and body size or mass.
Rationale: Client in acute respiratory distress is often anorectic because of dyspnea, sputum production, and medication effects. In addition, many COPD clients habitually eat poorly even though respiratory insufficiency creates a hypermetabolic state with increased caloric needs. As a result, client often is admitted with some degree of malnutrition. People who have emphysema are often thin, with wasted musculature.
2. Auscultate bowel sounds.
Rationale: Diminished or hypoactive bowel sounds may reflect decreased gastric motility and constipation (common complication) related to limited fluid intake, poor food choices, decreased activity, and hypoxemia.
3. Give frequent oral care, remove expectorated secretions promptly, and provide specific container for disposal of secretions and tissues.
Rationale: Noxious tastes, smells, and sights are prime deterrents to appetite and can produce nausea and vomiting with increased respiratory difficulty.
4. Encourage a rest period of 1 hour before and after meals. Provide frequent small feedings.
Rationale: Helps reduce fatigue during mealtime, and provides opportunity to increase total caloric intake.
5. Avoid gas-producing foods and carbonated beverages.
Rationale: Can produce abdominal distention, which hampers abdominal breathing and diaphragmatic movement and can increase dyspnea.
6. Avoid very hot or very cold foods.
Rationale: Extremes in temperature can precipitate or aggravate coughing spasms.
7. Weigh, as indicated.
Rationale: Useful in determining caloric needs, setting weight goal, and evaluating adequacy of nutritional plan. Note: Weight loss may continue initially despite adequate intake, as edema is resolving.
8. Consult dietitian or nutritional support team to provide easily digested, nutritionally balanced meals by mouth, supplemental or tube feedings, and parenteral nutrition.
Rationale: Method of feeding and caloric requirements are based on individual situation and specific needs to provide maximal nutrients with minimal client effort and energy expenditure.
9. Review serum albumin or prealbumin, transferrin, amino acid profile, iron, nitrogen balance studies, glucose, liver function studies, and electrolyte laboratory values as ordered.
Rationale: Determines deficits and monitors effectiveness of nutritional therapy.
10. Administer supplemental oxygen during meals, as indicated.
Rationale: Decreases dyspnea and increases energy for eating, enhancing intake.
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