Nursing Care Plan Imbalanced Nutrition

NURSING CARE PLAN NAME OF STUDENT: YEAR/GROUP: II-CN Group 1 B Assessment Subjective Cues “Nasusuka ko lang ang mga kinakain ko at pabawas ng pabawas ang timbang ko” as verbalized by the patient Objective Cues - Weight loss - Fatigue - Poor muscle tone - Nausea and vomiting VS as follows: BP: 90/60 mmHg HR: 58 bpm RR: 16 b / min Temperature: 37 ℃ CONCEPT: Nursing Diagnosis Imbalanced Nutrition: Less than Body Requirements related to inability to ingest, digest or metabolize nutrients as evidenced by weight loss, fatigue, poor muscle tone, nausea and vomiting Planning After series of nursing intervention the client should manifest the following: Short Term Objective After 1 week of nursing intervention, the patient will verbalize and demonstrate selection of foods or meals that will achieve cessation of weight loss and will display improved energy level Long Term Objective After 3 weeks of nursing intervention, the patient will be able to achieve a weight within her normal BMI range and she will demonstrate healthy eating pattern and choices and will be free of signs of malnutrition AREA: General Ward Intervention DATE: September 30, 2021 Rationale Evaluation Short Term:  Monitor vital signs  For baseline data  Weigh as indicated and valuate weight in terms of premorbid weight.  Indicator of nutritional adequacy of intake.  Assess ability to chew, taste, and swallow.  Auscultate bowel sound  Plan diet with client and SO, incorporating foods client likes or food from home. Encourage small, frequent meals and snacks of nutritionally dense foods and nonacidic foods and beverages. Encourage high calorie and nutritious food  Encourage client to sit up for meals  Limit foods that induce nausea or vomiting. Avoid serving very hot liquids and food and serve foods that are easy to swallow such as eggs, ice cream, or cooked vegetables.  Lesion in the mouth, throat and esophagus may be present which can limit the client ability to ingest food and reduce the desire to eat  Hypermotility of intestinal tract is common and is associated with vomiting and diarrhea, which may affect choice of diet or route  Including client in planning gives a sense of control of environment and may enhance intake. Fulfilling cravings for desired food may also improve intake.  Facilitates swallowing and reduces risk of aspiration.  These measures may be helpful in increasing food intake  Reduces discomfort associated with nausea or vomiting and a After 1 week of nursing intervention, the patient verbalized and demonstrated selection of foods or meals that help achieve cessation of weight loss and displayed improved energy level The goal was met Long Term: After 3 weeks of nursing intervention, the patient was able to achieve a weight within her normal BMI range and she demonstrated healthy eating pattern and choices and free of signs of malnutrition The goal was met  Provide frequent mouth care, observing secretion precautions  Facilitates swallowing and reduces risk of aspiration.  Administer medications, as indicated. for example:  Antiemetics, such as prochlorperazine (Compazine)  Appetite stimulants, such as dronabinol (Marinol), or megestrol (Megace)  Vitamin supplements  Consult with dietitian or nutritional support team clean mouth may enhance appetite  Identifies need for supplements or alternative feeding methods  Reduces incidence of nausea and vomiting, possibly enhancing oral intake  Marinol, an antiemetic, and Megace, an antineoplastic, act as appetite stimulants in the presence of AIDS  Corrects vitamin deficiencies resulting from decreased food intake and/or disorders of digestion and absorption in the GI system.  Provides for diet based on nutritional needs and appropriate route.