- Actual
- Risk for (Potential)
Related To: [Check those that apply]
- Inability to ingest foods
- Inability to digest foods
- Inability to absorb or metabolize foods
- Inability to procure adequate amounts of food
- Knowledge deficit
- Unwillingness to eat
- Increased metabolic needs caused by disease process or therapy
As evidenced by: [Check those that apply]
- Loss of weight with or without adequate caloric intake
- 10% to 20% below ideal body weight
- Documented inadequate caloric intake
- Insufficient muscle tone
- Food aversion
- Excessive air loss
- Diarrhea
- Pale mucous membrane
Patient’s Diagnosis: –
Date:-
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- verbalizes and demonstrates selection of foods or meals that will achieve a cessation of weight loss.
- Patient will weighs within 10% of ideal body weight.
- Others
Note: you need to indicate time frame/target as objective must be measurable.
| Nursing Interventions | Scientific Rationale |
|---|---|
| Document actual weight; do not estimate. | Patients may be unaware of their actual weight or weight loss due to estimating weight. |
| Obtain nutritional history; include family, significant others, or caregiver in assessment. | Patient's perception of actual intake may differ. |
| Determine etiologic factors for reduced nutritional intake. | Proper assessment guides intervention. For example, patients with dentation problems require referral to a dentist whereas patients with memory losses may require services such as Meals-on-Wheels. |
| Monitor or explore attitudes toward eating and food. | Many psychological, psychosocial, and cultural factors determine the type, amount, and appropriateness of food consumed. |
| Monitor environment in which eating occurs. | Fewer families today have a general meal together. Many adults find themselves eating on the run (at their desk, in the car) or relying heavily on fast foods with reduced nutritional components. |
| Encourage patient participation in recording food intake using a daily log. | Determination of type, amount, and pattern of food or fluid intake as facilitated by accurate documentation by patient or caregiver as the intake occurs; memory is insufficient. |
| Weigh patient weekly. | During aggressive nutritional support, patient can gain up to 0.5 lbs per day. |
| Consult dietitian for further assessment and recommendations regarding food preferences and nutritional support. | Dietitians have a greater understanding of the nutritional value of foods and may be helpful in assessing specific ethnic or cultural foods. |
| Establish appropriate short- and long-range goals. | Depending on the etiologic factors of the problem, improvement in nutritional status may take a long time. Without realistic short-term goals to provide tangible rewards, patients may lose interest in addressing this problem. |
| Encourage exercise. | Metabolism and utilization of nutrients are enhanced by activity. |
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