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
 Monitor or to a dentist)
P- 59 bpm
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
 Student Nurses’ Community

Electrolyte imbalance recording food appropriateness of

intake using a food consumed.
daily log.
Determination of
 Monitor patient type, amount, and
daily or weekly pattern of food or
fluid intake as
 Provide
facilitated by accurate
companionship
documentation by
during mealtime.
patient or caregiver as
 Build up and the intake occurs;
persuade a memory is
pleasing milieu for insufficient.
meals. Dish up
During aggressive
foods in well-
nutritional support,
ventilated,
patient can gain up to
pleasing
0.5 lbs per day.
environment, with
unhurried Attention to the social
ambiance, friendly aspects of eating is
company. important in both the
hospital and home
 Give frequent
setting.
mouth care,
noting secretion Pleasing milieu helps
precautions. in lowering stress and
Prevent us of is more favorable to
alcohol-containing eating. It also
mouthwashes encourages
socialization and
 Encourage
maximizes patient
exercise as
Student Nurses’ Community

indicated comfort when eating

Collaborative difficulty cause
discomfiture.
 Ask dietician for
further evaluation Lowers discomfort
and suggestions related with nausea or
regarding food vomiting, oral lesions,
partialities and mucosal dryness, and
nutritional halitosis. Clean mouth
assistance. may improve appetite

Metabolism and
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.