Student Nurses’ Community

NURSING CARE PLAN ─ Imbalanced Nutrition (Less than body requirement)

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE: Imbalanced Nutrition Biologic, After 2 weeks of Independent: Patients may be After 2 weeks of
Less than Body psychologic, nursing intervention, unaware of their nursing intervention,
Patient verbalizes “I economic factors  Document actual
Requirements Related the patient will be able actual weight or goal met. Patient was
always feel weak and ↓ weight using
To Inability to ingest or to: weight loss due to able to verbalize
tired” Impair a person’s weighing scale; do
digest food or to estimating weight understanding and
ability to ingest or  Verbalize and not estimate
absorb nutrients demonstrate selection
digest food/ absorb demonstrate Patient's perception
because of biologic,  Obtain nutritional of meals that help in
nutrients selection of foods of actual intake may
psychologic, or history; include achieving cessation of
↓ or meals that will differ.
OBJECTIVE: economic factors Imbalanced family, significant weight loss; and
achieve a cessation
Nutrition others, or With proper gained at least 10% of
Weight loss of weight loss.
(less than body caregiver in assessment you may ideal body weight.
Poor muscle tone requirements)  Have weight within assessment. be able to plan
10% of ideal body appropriate
 Determine
weight. interventions (i.e.,
etiologic factors
Vital signs: patients with
for reduced
dentation problems
t- 37 C nutritional intake
may require referral
P- 59 bpm  Monitor or to a dentist)
explore attitudes
Many psychological,
Rr – 17 br/min toward eating and
psychosocial, and
food.
BP 90/60 mmHg cultural factors
 Encourage patient determine the type,
participation in amount, and
appropriateness of
 Student Nurses’ Community
Electrolyte imbalance recording food food consumed.
intake using a
Determination of
daily log.
type, amount, and
 Monitor patient pattern of food or
daily or weekly fluid intake as
facilitated by accurate
 Provide
documentation by
companionship
patient or caregiver as
during mealtime.
the intake occurs;
 Build up and memory is
persuade a insufficient.
pleasing milieu for
During aggressive
meals. Dish up
nutritional support,
foods in well-
patient can gain up to
ventilated,
0.5 lbs per day.
pleasing
environment, with Attention to the social
unhurried aspects of eating is
ambiance, friendly important in both the
company. hospital and home
setting.
 Give frequent
mouth care, Pleasing milieu helps
noting secretion in lowering stress and
precautions. is more favorable to
Prevent us of eating. It also
alcohol-containing encourages
mouthwashes socialization and
maximizes patient
 Encourage
comfort when eating
exercise as
difficulty cause
Student Nurses’ Community
indicated discomfiture.
Collaborative
Lowers discomfort
 Ask dietician for related with nausea or
further evaluation vomiting, oral lesions,
and suggestions mucosal dryness, and
regarding food halitosis. Clean mouth
partialities and may improve appetite
nutritional
Metabolism and
assistance.
utilization of nutrients
are enhanced by
activity.

Dieticians have a
broader knowledge of
the nutritional value
of foods and may be
useful in evaluating
specific ethnic or
cultural foods.