malnutrition ncp

8/19/2019 Malnutrition NCP

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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATIONSubjective:

“ Walang ganang kumain anganak ko “ as verbalized by themother “

Objective:

Lack of interest in foodLoss of weightWeaknessVomiting after meals“Imbalance Nutrition less than

body requirements related toloss of appetite as evidenced bylack of interest in food loss

of weight weakness and vomiting

after meal!

Inference:

Malnutrition

is the conditionthat results from taking anunbalanced diet in which certainnutrients are

lacking in e"cess#too high an intake$ or in thewrong proportions%

It is a broad term which refers toboth

uner nutrition

#subnutrition$ and

over nutrition

%Individuals are malnourished orsuffer from under nutrition if their diet does not provide

themwith adequate calories andprotein for maintenance andgrowth or they cannot

fullyutilize the food they eat due toillness%

S!ort Ter" Goal:

“&fter ' hour of nursing

intervention client will be able to(onsume at least )*+ of breakfast lunch and dinnertraysat the end of the day

!

Lon# Ter" Goal:

“&fter ' week of Nursing

intervention client will be able toe"hibit no sign and symptoms of malnutrition and will be

able togain , pounds at the end of theweek%

Ine$enent:

Weigh client daily%

%ei#!t lo&&or #ain i& i"$ortant a&&e&&"entinfor"ation'-tay with client during meals

toa&&i&t a& neee an to offer&u$$ort an encoura#e"ent'

.eep strict documentation of intake output and caloriecount%

T!i& infor"ation i&nece&&ar( to "a)e an accuratenutritional a&&e&&"ent an"aintain

client &afet('

-uggest liquid drinks to themother



for &u$$le"entalnutrition'

/iscourage beverages that arecaffeinated and carbonated%

T!e&e "a( ecrea&e a$$etitean lea to &atiet('*ollaborative:

(onsult dietitian for furtherassessment andrecommendations regardingfood preferences

and nutritionalsupport%

Dietitian& !ave aS!ort Ter" #oal:0oal met after ' hour of nursingintervention client consumed)*+ of her breakfast )*+

lunchand )*+ at dinner trays at theend of the day%

Lon# Ter" Goal:

0oal met after ' week of nursingintervention client e"hibit nosigns and symptoms

of malnutrition and gain , poundsat the end of the week%

NURSING DIAGNOSIS: Altered nutrition: less thanbody requirements

related to:

1. decreased oral intake associated with:

A. anoreia resultin! "rom decreased acti#ity$ de%ression and social isolation$ the e""ect o" ne!ati#e nitro!en balance$ and early satiety that occurs with decreased!astrointestinal motility

&. di""iculty "eedin! sel" as a result o" im%aired or limited %hysical mobility'

(. increased nutritional needs associated with an imbalance in the rate o" catabolism andanabolism )in the immobili*ed %erson$ catabolic %rocesses occur at a "aster rate than anabolic%rocesses+.

Desired Outcome

The client will maintain an adequate nutritional status as evidenced by:

1. weight within normal range for client

2. normal BUN and serum albumin, ct, b, and lym!hocyte levels

". no further decline in strength and activity tolerance

#. healthy oral mucous membrane.



Nursin! Actions and Selected Purposes/Rationales

1. $ssess for and re!ort signs and sym!toms of malnutrition:

$. weight below client%s usual weight or below normal for client%s age, height,and body frame

B. abnormal BUN and low serum albumin, ct, b, and lym!hocyte levels

&. wea'ness and fatigue

(. sore, inflamed oral mucous membrane

). !ale con*unctiva.

2. +onitor !ercentage of meals and snac's client consumes. e!ort a !attern of

inadequate inta'e.

". -m!lement measures to maintain an adequate nutritional status:

$. !erform actions to improve oral intake:

-. obtain a dietary consult if necessary to assist client in selecting

foodsfluids that meet nutritional needs, are a!!ealing, and adhere to!ersonal and cultural !references

--. encourage a rest !eriod before meals to minimize fatigue

---. maintain a clean environment and rela/ed, !leasant atmos!here

-0. !rovide oral hygiene before meals (removes unpleasant tastes, whichoften improves the taste of foods/fluids)

0. serve frequent, small meals rather than large ones if client is wea',fatigues easily, andor has a !oor a!!etite

0-. im!lement measures to !revent gastrointestinal distention e.g.!erform actions to !revent consti!ation, administer !rescribed

gastrointestinal stimulants in order to prevent feeling of fullness and

early satiety

0--. encourage significant others to bring in client%s favorite foods unlesscontraindicated and eat with himher to make eating more of a

familiar social experience

0---. encourage significant others to be !resent to assist client with meals if

needed

-3. allow adequate time for meals4 reheat foodsfluids if necessary



3. limit fluid inta'e with meals unless the fluid has high nutritionalvalue to reduce early satiety and subsequent decreased food intake

3-. enable client to feed self if !ossible4 if client needs to be fed, offer

foodsfluids in the order heshe !refers

3--. increase activity as allowed (activity usually promotes a sense of wellbeing, which can improve appetite)

B. ensure that meals are well balanced and high in essential nutrients4 offerhigh5!rotein, high5calorie dietary su!!lements if indicated

&. administer vitamins and minerals if ordered.

#. 6erform a calorie count if ordered. e!ort information to dietitian and !hysician.

7. &onsult !hysician about an alternative method of !roviding nutrition e.g. !arenteralnutrition, tube feedings if client does not consume enough food or fluids to meet

nutritional needs.

malnutrition ncp

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