Nursing Care Plans for Nutritional Problems

Patient receiving Enteral Nutrition Nursing Diagnosis* Impaired Nutritional Status Etiology: Inability to ingest food due to physiologic and/or psychologic factors Supporting data: Body weight 20% or more below ideal weight range, pale conjunctivae and mucous membranes, poor muscle tone Patient Goal Achieves adequate nutritional status Outcomes (NOC) Nutritional Status  Nutrient intake _____  Food intake _____  Fluid intake _____  Weight/height ratio _____  Hydration _____  Muscle tone_____ Nutritional Status: Biochemical Measures  Hematocrit _____  Serum albumin ______ Measurement Scale 1 = Severe deviation from normal range 2 = Substantial deviation from normal range 3 = Moderate deviation from normal range 4 = Mild deviation from normal range 5 = No deviation from normal range Interventions (NIC) and Rationales Nutrition Therapy  Determine, in collaboration with the dietitian, the number of calories and type of nutrients needed to meet nutrition requirements.  Monitor appropriateness of diet orders to meet daily nutritional needs.  Determine need for enteral tube feedings to ensure adequate nutrition.  Discontinue use of tube feedings as oral intake is tolerated. Enteral Tube Feeding  Monitor weight three times a week initially, decreasing to once a month to make adjustments as needed in calorie intake.  Keep open containers of enteral feeding refrigerated to prevent bacterial growth.  Discard enteral feeding containers and administration sets every 24 hours because they expire.  Refill feeding bag every 4 hours to avoid contamination of formula.  Monitor for presence of bowel sounds every 4-8 hours to ensure presence of gastrointestinal function. Nursing Diagnosis Risk for Aspiration Risk factors: Gastrointestinal tubes and tube feedings Patient Goal * Nursing diagnoses listed in order of priority. Has no aspiration Outcomes (NOC) Aspiration Prevention  Identifies risk factors _____  Avoids risk factors _____  Positions self upright for eating/drinking _____  Remains upright for 30 minutes after eating _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated Interventions (NIC) and Rationales Enteral Tube Feeding  Check tube every 4 hr for placement to ensure the tube is in the proper position.  After attaining the enteral feeding rate goal, decrease gastric residual monitoring to every 6 to 8 hours in non– critically ill patients or continue every 4 hours in critically ill patients.  Hold tube feedings if residual is greater than 150 mL or more than 110% to 120% of the hourly rate in adults.  Elevate head of the bed 30 to 45 degrees during feedings to prevent aspiration.  Monitor patient for sensation of fullness, nausea, and vomiting because these are signs of gastric retention.  Discontinue feedings 30 to 60 minutes before putting patient in a head-down position to prevent aspiration. Nursing Diagnosis Fluid Imbalance Risk factors: diarrhea, inadequate water intake Supporting data: Decreased BP and urine output, increased heart rate, change in mental status, thirst, weakness, weight loss, dry mucous membranes Patient Goal Maintains adequate fluid volume Outcomes (NOC) Hydration  Skin turgor _____  Moist mucous membranes _____  Fluid intake____  Urine output _____  Serum sodium _____  Cognitive function _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised Interventions (NIC) and Rationales Fluid/Electrolyte Management  Assess patient’s buccal membranes, sclera, and skin for indications of altered fluid and electrolyte balance (e.g., dryness, cyanosis) to identify signs of fluid volume deficit.  Provide free water with tube feedings to compensate for high-concentration enteral feedings. Diarrhea Management  Identify factors (e.g., medications, bacteria, tube feedings) that may cause or contribute to diarrhea to plan appropriate interventions. Enteral Tube Feeding  Check gravity drip rate or pump rate every hour to maintain adequate fluid intake. Outcomes (NOC) Interventions (NIC) and Rationales  Slow tube feeding rate and/or decrease strength to control diarrhea.  Irrigate the tube every 4 to 6 hours during continuous feedings and after every intermittent feeding to provide free water. eNursing Care Plan 39-2 Patient receiving Parenteral Nutrition Nursing Diagnosis Risk for Infection Risk factors: Presence of a central venous catheter, administration of solutions that support rapid bacterial growth, decreased defense mechanisms Patient Goal Does not develop an infection Outcomes (NOC) Infection Severity  Fever ___  Chilling ___  Malaise ___  Blood culture colonization ___  Wound site culture colonization ___  WBC count elevation ___ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None Interventions (NIC) and Rationales Infection Control  Maintain an optimal aseptic environment during bedside insertion of central lines to minimize the possibility of infection.  Maintain an aseptic environment while changing PN tubing and bags to minimize the possibility of infection.  Change peripheral IV and central line sites and dressings according to current CDC guidelines to prevent infection.  Perform hand hygiene before and after each patient care activity to minimize possibility of infection.  Encourage rest so that nutrition is used for healing purposes. Infection Protection  Monitor for systemic and localized signs and symptoms of infection to ensure early detection of infection.  Monitor WBC count and WBC differential (especially neutrophils) to ensure early detection of infection. Nursing Diagnosis* * Nursing diagnoses listed in order of priority. Hyperglycemia Etiology: Carbohydrate load in parenteral formula, fluid imbalance, compromised regulatory mechanisms Supporting data: Elevated blood glucose levels Patient Goal Maintains blood glucose levels within target range Nursing Goals Blood Glucose Level: Hyperglycemia Severity  Blood glucose _____  Glycosated hemoglobin _____ Nursing Interventions and Rationales Hyperglycemia Management  Monitor for manifestations of hyperglycemia such as thirst, polyuria, confusion, elevated blood glucose, blurred vision, dizziness, nausea and vomiting, and dehydration to plan appropriate treatment.  Check capillary blood glucose every 4 to 6 hours to Measurement Scale detect glucose imbalances. 1 = Severe deviation from  Maintain accurate infusion rate to control the amount of normal range glucose administered and prevent fluctuations in blood 2 = Substantial deviation from glucose levels. normal range  Administer insulin as prescribed to maintain appropriate 3 = Moderate deviation from blood glucose levels. normal range  Report deviations from prescribed parameters to identify 4 = Mild deviation from and treat complications early. normal range 5 = No deviation from normal range Nursing Diagnosis* Electrolyte Imbalance Etiology: Parenteral nutrition, fluid imbalance, hyperglycemia, compromised regulatory mechanisms Supporting data: Muscle weakness, dysrhythmias, abdominal cramps, diarrhea, tremors, paresthesias, nausea and vomiting, tetany, altered mental status Patient Goal Maintains electrolyte levels within normal range Nursing Goals Electrolyte Balance  Potassium _____  Sodium _____  Magnesium _____  Phosphorus _____ * Nursing Interventions and Rationales Electrolyte Monitoring  Monitor serum electrolyte levels daily to identify and treat complications early.  Assess for the presence of other conditions that increase risk of electrolyte imbalance to identify and treat Nursing diagnoses listed in order of priority. Nursing Interventions and Rationales complications early.  Calcium _____  Report deviations from prescribed parameters to identify and treat complications early.  Assess for manifestations of calcium, potassium, sodium, Measurement Scale magnesium, and phosphorus imbalances. 1 = Severe deviation from  Maintain accurate infusion rate to control the amount of normal range electrolytes and fluids administered and prevent 2 = Substantial deviation from fluctuations in levels. normal range Nursing Goals 3 = Moderate deviation from normal range 4 = Mild deviation from normal range 5 = No deviation from normal range PN, Parenteral nutrition; WBC, white blood cell.