Alteration in Nutrition: Less Than Body Requirements

Alteration in Nutrition: Less Than Body Requirements

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Dysphagia caused by:_________________
(_) Absorptive disorders
(_) Anorexia
(_) Allergy
(_) Burns
(_) Cancer
(_) Chemotherapy
(_) Chemical dependence
(_) Crash or fad diet
(_) Depression
 (_) Inability to obtain food
(_) Infection
(_) Lack of knowledge of adequate nutrition
(_) Nausea and vomiting
(_) Radiation Therapy
(_) Social isolation
(_) Stress
(_) Trauma
(_) Other:___________________________
__________________________________
__________________________________

As evidenced by:
[Check those that apply]
Major:
(Must be present)		 (_) Reported inadequate food intake less than recommended daily allowance with or without weight loss and/or actual or potential metabolic needs in excess of intake.
Minor:
(May be present)		 (_) Weight 10% to 20% or more below ideal for height and frame.
(_) Tachycardia on minimal exercise and bradycardia at rest.
(_) Muscle weakness and tenderness.
(_) Mental irritability or confusion.
(_) Decreased serumm albumin.

Date &
Sign.		 Plan and Outcome
[Check those that apply]		 Target
Date:		 Nursing Interventions
[Check those that apply]		 Date
Achieved:
The patient will:

(_) Experience adeuqate nutrition through oral intake.

(_) Experience an increase in the amount or type of nutrients ingested.

(_) Gain weight.

(_) Other:

 (_) Assess and document patient's dietary history, patters of ingestion, intolerance to foods.

(_) Assess patient likes and dislikes. Inform dietary.

(_) Teach techniques to maintain adequate nutritional intake and stimulate appetite:

  • administer/instruct pt. on good oral hygiene before and after feedings
  • maintain pleasant environment for patient

(_) Determine proper denture fit and profice adhesive as necessary.

(_) Increase social contact with meals by:____________________
_______________________

(_) Plan care so that unpleasant/painful tests/tx's don't take place before meals.

(_) Medicate pt. for pain 2 hrs before meals per physician's orders.

(_) Consult with dietitian re:

  • calorie count
  • change in food consistency
  • spacing meals
  • provision of high caloric supplements
  • provision of high protein supplementation
  • food intolerances/preferences
  • extra fluids on tray
  • dietetic teaching, food selelction
  • therapeutic diet restrictions:
    __________________

(_)Consult with PT/PT re:

  • strengthening exercises
  • prosthetic devices
  • swallowing disorders

(_) Environmental support to improve intake:

  • be sure pt. is alert and responsive before eating
  • sit upright 60-90 degrees for 15-20 min. before, during & after eating
  • decrease distractions
  • demonstrate patience by providing specific directions until finished
  • assure good mouth care

(_) Weigh patient q______
at _______ a.m./p.m.

(_) Other:________________
________________________
________________________
________________________

__________________________
Patient/Significant other signature

__________________________
RN signature

Thursday, May 15, 2008 | Labels: |

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