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NCLEX & CGFNS Practice Questions
Imbalance Nutrition: Less than Body Requirements
  • 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: –
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Objective/Expected Outcome;The patient will:

  • 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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