Tung Wah College

School of Nursing
Bachelor of Health Science (Honours) in Nursing – NY Year 2
AY2022-23, Semester 1

NUR1013 Fundamental of Nursing II

Individual Written assignment: Nursing Care Plan
Case: Tutorial 1 – Care of patients with nutritional imbalance

Student Name (Full): Lee Tin Yan, Emma__________________

Student ID: 21002276_____________

Tutorial Group: 06_________________

Tutorial Teacher: Agnes

Total Words: ____588______

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 Individual Written Assignment: Care Plan

Assessment Problem Goals Interventions with rationales Evaluation (Expected outcomes)

Objective data: Nutrition imbalance Short term goals: I: Make a nutrition screen for the patient in 24 1. Patient will be willing to eat
Tired and skinny which under body Patient will have hours. (Ackely et al., 2020) and drink while hospitalization.
looking required related to sufficient nutrient R: Study showed that recent nutrition 2. Patient’s BMI can gain from
Dry skin reduced appetite due to intake, as evidenced by intervention can decrease the length of staying 15.9 to at lease 18.5 within 2
Pulse:103/min depression as evidenced getting passed the blood hospital. months, and her look will be
Mild depression by abnormal low BMI, test in 1 weeks after less skinny.
in past medical lack of appetite, and admission. I: Refer to dietitian for a full nutritional 3. Patient’s level of albumin in
history. level of albumin in assessment and intervention. (Ackely et al., 2020) blood test can gain from 28g/L
Poor appetite for blood is lower than Long term goal: R: there are characteristics for confirming to normal range which is 35 to
recent 4-6 normal. Patient will understand malnutrition, which are inadequate energy 50g/L in a week.
months. significance of having intake, loss of weight, muscles, subcutaneous fat, 4. Patient is willing to move more
Refusing eating sufficient nutrient intake restricted fluid accumulation, and reduced to enhance appetite.
or drinking in and willing to increase functional status.
these few days. food intake within 2
Only tolerated weeks. I: detect whether patient is willing and able to
50-100ml of eat, and condition of patient’s appetite. (Ackely
fluid for every et al., 2020)
meal R: depression, poor food intake is linked with
BMI:15.9 increased probability of losing weight, lower
(underweight) BMI, and insufficient nutrition.
Blood albumin:
28 (less than I: Provide oral nutritional supplements (ONS)
normal) after admission and advice having ONS during
Subjective data: hospital stay. (Ackely et al., 2020)
Patient R: ONS can reduce time for malnutrition
complaint of patients to stay in hospital by having lower
mild dizziness chance of underfeeding.
and headache

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with pain score 3 I: Prevent disruption while having meal and
out of 10. provide camaraderie, to produce a smooth and
harmonious environment for meals. (Ackely et
al., 2020)
R: Implementation of preserved mealtimes and
provide extra nursing assistance can advance
amount of food intakes.

I: Allow patients to have snacks or meals even

it’s not mealtime. (Ackely et al., 2020)
R: There are more chance for patients to have
food intake voluntarily, which encourage
patients to have more food intake.

I: Arrange oral cleaning before meal. (Ackely et

al., 2020)
R: Better oral hygiene can improve appetite.

I: Examine patient’s level of eagerness to eat.

(Ackely et al., 2020)
R: Insufficient food intake among elderly is
usually linked to poor appetite, cancer, need for
help with feeding.

I: Provide food with high protein. (Ackely et al.,

2020)
R: the requirement of protein is easier to meet
than other energy requirements.

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References

Ackely, B.J., Ladwig, G.B., Makic, M. B. F., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to
planning care (12th ed.). Elsevier