Nursing Care Plan

Imbalanced Nutrition: less than body requirement

In Partial Fulfillment
of the Requirements on NCM 203 RLE

Submitted to:

Mrs. Kristine Monica Reyes,RN

Clinical Instructor

Submitted By:

Tuansi, Al-Khusairy A.

BSN-1F

August 31, 2021

 Name of Patient: X Age/Sex: 38/F Ward: X Room and Bed no. 203-C

Chief Complaint: Worsening joint pain over several months Diagnosis:_______________

Attending Physician: Dr. Z

Dat Cues/Clues Need Nursing Patient Nursing Intervention Implementat Evaluation

e/ Diagnosis Outcome ion
Tim
e

Subjective cues: N Imbalance Within 2 ● Give the patient August 31,

A Nutrition: less than weeks of feso4 2021 @
U
U -Patient complains body requirement nursing R: Ferrous 1 3:00 PM
G about pains in her T related to low intervention, sulfate is an iron “GOAL MET”
joints which was appetite due to the patient will supplement
U R
worsening over chronic pain as be able to: used to treat or After 2 weeks
S several months. I evidenced by prevent low of nursing
T -The joints that weight loss of 4 kg Verbalize and blood levels of intervention,
T
are most painful over 3 months, demonstrate iron (e.g., for the patient was
are the small I looks pale and selection of anemia or able to:
3 joints of the hands clinically anemic foods or during
O
1, and feet. and low levels of meals that will pregnancy). Iron Verbalize and
-She has had no N hemoglobin. achieve a is an important demonstrate
previous serious termination of mineral that the selection of
A
illnesses. RATIONALE: weight loss body needs to foods or meals
2 L The patient is in and gain 4 produce red that will
0 chronic pain pounds. blood cells and achieve a
2 Objective cues: resulting in loss of keep you in termination of
1 / appetite, good health. weight loss and
-Her joints are insufficient dietary gained 4
most stiff on intake, and weight ● Document 2 pounds.
waking in the loss. These factors actual weight
@ mornings. M don't help the using weighing
7-3 -She has lost 4 kg patient’s anemia scale; do not
E
SHI in weight over 3 and low estimate
FT months. T hemoglobin levels. R: Patients
-She looks pale The pain and loss may be unaware
A
and clinically of appetite impair of their actual
anemic B a person’s ability weight or weight
● Hemoglobi to ingest or digest loss due to
O
n 8.9 g/dL food / absorb estimating
-Her proximal L nutrients leading weight
interphalangeal to an Imbalanced
I
joints and Nutrition ● Obtain 3
metacarpophalang C (less than body nutritional
eal joints are requirements) history; include
swollen and family,
painful with significant
effusions present others, or
-Her caregiver in
metatarsophalang assessment.
eal joints are also R: Patient's
tender perception of
-Physical actual intake
examination is may differ.
otherwise normal
-Vital Signs were ● Determine 4
taken as follows: etiologic factors
o T: 36.5oC for reduced
o PR: 82 nutritional intake
o RR: 17 R: With
o HR: 82 proper
o BP: 120/80 assessment you
-Mean corpuscular may be able to
volume (MCV): 87 plan appropriate
fL interventions
-White cell count: (i.e., patients
7.2 x 109/L with dentation
-Platelets: 438 x problems may
109/L require referral
-Erythrocyte to a dentist)
sedimentation rate
(ESR): 78 mm/h ● Monitor or 5
-Sodium: 141 explore attitudes
mmol/L toward eating
-Potassium 3.9 and food.
mmol/L R: Many
-Urea: 6.9 mmol/L psychological,
-Creatinine:125 psychosocial,
μmol/L and cultural
-Glucose factors
4.6 mmol/L determine the
-Albumin 33 g/L type, amount,
-Urinalysis: and
no protein; appropriateness
no blood; of food
no glucose consumed.

● Encourage
patient 6
participation in
recording food
intake using a
daily log.
R:
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.

● Provide
companionship 7
during mealtime.
R: Attention
to the social
aspects of
eating is
important in
both the hospital
and home
setting.

● Build up and
persuade a 8
pleasing
environment for
meals. Dish up
foods in
well-ventilated,
pleasing
environment,
with unhurried
 ambiance,
friendly
company.
R: Pleasing
environment
helps in
lowering stress
and is more
favorable to
eating. It also
encourages
socialization and
maximizes
patient comfort
when eating
difficulty cause
discomfiture.

● Ask dietician for

further 9
evaluation and
suggestions
regarding food
partialities and
nutritional
assistance.
R: Dieticians
have a broader
knowledge of
the nutritional
value of foods
and may be
useful in
 evaluating
specific ethnic
or cultural foods.

References:

Gil Wayne, BSN, R.N. (2021, August 8,). Acute Pain Nursing Care Plan

https://nurseslabs.com/acute-pain/

J. Anat. (2009, February). Exercise and osteoarthritis

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2667877/

Matt Vera, BSN, RN. (2019, April 11). 6 Rheumatoid Arthritis Nursing Care Plans
https://nurseslabs.com/6-rheumatoid-arthritis-nursing-care-plans/.

RNSpeak. (2021, April 10). Rheumatoid Arthritis [Actual Diagnoses] Nursing Care Plan.
https://rnspeak.com/rheumatoid-arthritis-nursing-care-plan/.

Yvette Brazier. (2021, May 23). What are 10 risk factors for rheumatoid arthritis?.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2667877/

Mayo Clinic. (2020, December 5). Rheumatoid arthritis - Diagnosis and treatment.
https://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/diagnosis-treatment/drc-20353653.
 Joachim Listing. The risk of infections associated with rheumatoid arthritis, with its comorbidity and treatment.
https://academic.oup.com/rheumatology/article/52/1/53/1830871.

Debra Fulghum Bruce, PhD. (2021, May 15). Rheumatology and Rheumatic Diseases.
https://www.webmd.com/rheumatoid-arthritis/an-overview-of-rheumatic-diseases.

Howard R Smith. (2021, March 5). Rheumatoid Arthritis (RA) Treatment & Management.
https://emedicine.medscape.com/article/331715-treatment.

Barbara H. Seeber. (2016, October 19). 5 Things My Husband Does to Manage His Rheumatoid Arthritis Symptoms.
https://www.everydayhealth.com/columns/white-seeber-grogan-the-remedy-chicks/ways-to-manage-rheumatoid-arth
ritis/.

Classification of cues/clues
SUBJECTIVE OBJECTIVE

Patient complains about pains in her joints which was worsening Her joints are most stiff on waking in the mornings.
over several months.

The joints that are most painful are the small joints of the hands She has lost 4 kg in weight over 3 months.
and feet.

The patient felt tired She looks pale and clinically anemic

She is a non smoker and occasionally drinks Her proximal interphalangeal joints and metacarpophalangeal
joints are swollen and painful with effusions present

She has had no previous serious illnesses Her metatarsophalangeal joints are also tender

Physical examination is otherwise normal

Classification of cues/clues according to Gordon’s Functional Health Patterns
Health perception/health Nutritional/Metabolic: Elimination: Activity/Exercise:
management: ● Weight loss of 4 kg ● Urinalysis: ● The patient
● Physical Examination over 3 months no protein experienced joint
by her general ● Looks pale and is no blood stiffness on waking in
practitioner clinically anemic no glucose the mornings
● Hemoglobin 8.9 g/dL ● T: 36.5oC
● Mean corpuscular ● PR: 82
volume (MCV): 87 fL ● RR: 17
● White cell count: 7.2 x ● HR: 82
10⁹/L ● BP: 120/80 mmHg
● Platelets: 438 x 10⁹/L
● Erythrocyte
sedimentation rate
(ESR): 78 mm/h
● Sodium 141 mmol/L
● Potassium 3.9 mmol/L
● Urea: 6.9 mmol/L
● Creatinine: 125 µmol/L
● Glucose 4.6 mmol/L
● Albumin 33 g/L

Cognitive/Perceptual: Sleep/Rest: Self Perception/Self-Concept: Role/Relationship:

● The patient perceives ● The patient felt tired. ● Wife
the most painful joints ● Mother
are the small joints of ● Works as a legal
the hands and feet secretary
● Proximal
interphalangeal joints
and
metacarpophalangeal
joints are swollen and
painful with effusions
present
● Metatarsophalangeal
joints are tender
Sexual/Reproductive: Coping/Stress Tolerance: Value-Belief:
● The patient has two ● Diclofenac tablets as
children pain reliever