Friday, November 26, 2010

Imbalanced Nutrition: Less than Body Requirements

Imbalanced Nutrition: Less than Body Requirements

NANDA Definition
This nursing diagnosis means, the intake of nutrients is insufficient to meet metabolic needs.

Discussion of the Problem
Adequate nutrition plays an important role in healing and recovery. Imbalance nutrition: less than body requirements refers to an intake of nutrients insufficient to meet daily requirements because of inadequate food intake or improper digestion and absorption of food. An inadequate food intake may be caused by the inability to acquire or prepare food, inadequate knowledge about essential nutrients and a balanced diet, discomfort during or after eating, dysphagia, anorexia, nausea, or vomiting. Improper digestion and absorption of nutrients may be caused by an inadequate production of hormones or enzymes or b medical conditions resulting in inflammation or obstruction of the gastrointestinal tract. It can also be affected by the following: gastrointestinal [GI] malabsorption, cancer, burns, muscle weakness, poor dentition, activity intolerance, pain, substance abuse, lack of financial resources to obtain nutritious foods, depression, boredom, trauma, surgery, sepsis, burns. In addition, medical conditions that could alter nutrition are as follows: AIDS, anemias, cancer, COPD, asthma, cirrhosis of the liver, diabetes mellitus, diabetic ketoacidosis, anorexia nervosa, bulimia nervosa, inflammatory bowel disease, ulcerative colitis, Crohn’s disease, ileocolitis, pancreatitis, pulmonary tuberculosis, radical neck surgery,, laryngectomy, renal dialysis, ventilatory assistance, and postoperative conditions. The major goals for this problem is to maintain or restore optimal nutrition status, promote healthy nutritional practices, prevent complication associated with malnutrition and regain specified weight.

Nursing Interventions Classification (NIC)
  • Eating Disorder Management
  • Enteral Feeding/TPN Administration
  • Enteral Tube Feeding
  • Hyperglycemia Management
  • Nutrition Management
  • Nutrition Monitoring
  • Nutrition Therapy
  • Weight Gain Assistance

Nursing Outcomes Classification (NOC)
  • Knowledge: Diet
  • Nutritional Status: Food and Fluid Intake
  • Nutritional Status: Nutrient Intake
  • Treatment Behavior: Illness or Injury

Goal and Objectives
  • Patient or significant other will express and show selection of foods or meals that will attain a termination of weight loss.
  • Patient will demonstrate behaviors, lifestyle changes to recover and/or keep appropriate weight.
  • Patient will demonstrate nutritional ingestion sufficient to meet metabolic needs as manifested by stable weight or muscle-mass measurements, positive nitrogen balance, tissue regeneration and display improved energy level.
  • Patient will experience no signs of malnutrition.
·         Patient will Indicate understanding of significance of nutrition to healing process and general health.
·         Patient will ingest proper amounts of calories or nutrients.
  • Patient will maintain weight or display weight gain on the way to preferred goal, with normalization of laboratory values.
  • Patient will weigh within 10% of ideal body weight (IBW).

Subjective and Objective Data
  • 10% to 20% below ideal body weight or weight below normal for age, height, and build
·         Abdominal cramping, hyperactive bowel sounds, diarrhea
·         Abnormal laboratory results: vitamin/mineral and protein deficiencies, electrolyte imbalances
  • Amenorrhea
  • Bradycardia; cardiac irregularities; hypotension
·         Changes in gastric motility and stool characteristics
·         Changes in gums, oral mucous membranes
·         Decreased tolerance for activity, weakness
·         Decreased triceps skin-fold measurement
  • Diarrhea
  • Documented inadequate caloric intake
  • Excessive loss of hair; increased growth of hair on body (lanugo)
  • Hypothermia
  • Imbalances in nutritional studies
  • Increased ketones (end product of fat metabolism)
  • Increased urinary output, dilute urine
·         Lack of interest in food, aversion to eating, altered taste sensation
·         Loss of muscle mass/subcutaneous fat, and development of negative nitrogen balance
  • Loss of weight with or without adequate caloric intake, decreased subcutaneous fat/muscle mass (wasting)
  • Pale conjunctiva; poor skin turgor
·         Sore, inflamed buccal cavity
  • Weakness of muscles required for swallowing or mastication

Related Factors
  • Abnormal bowel function
  • Altered absorption and metabolism of ingested foods: reduced peristalsis (visceral reflexes), bile stasis
  • Altered feedback mechanisms of desire to eat, taste, and smell because of surgical/structural changes, radiation, or chemotherapy
·         Anorexia, restricted oral intake, indigestion, early satiety (ascites)
  • Chronic/excessive laxative use
·         Dyspnea; sputum production
·         Failure to absorb nutrients necessary for formation of normal RBCs
·         Fatigue
  • Hypermetabolic state: release of stress hormones (e.g., epinephrine, cortisol, and growth hormone), infectious process
·         Inability or altered ability to ingest, digest and/or metabolize nutrients: nausea/vomiting, hyperactive gag reflex, intestinal disturbances, GI tract infections, fatigue
  • Inadequate diet
  • Increased metabolic needs caused by disease process or therapy
·         Increased metabolic rate/nutritional needs (fever/infection, can be as much as 50%–60% higher than normal proportional to the severity of injury)
  • Insufficient financial resources
  • Insulin deficiency (decreased uptake and utilization of glucose by the tissues, resulting in increased protein/fat metabolism)
  • Knowledge deficit
  • Loss of digestive enzymes and insulin (related to pancreatic outflow obstruction or necrosis/autodigestion)
  • Loss of peptides and amino acids (building blocks for proteins) during dialysis
  • Medically restricted intake; fear that eating may cause diarrhea or temporary or permanent alteration in mode of food intake
·         Medication side effects; anorexia, nausea/vomiting
·         Protein catabolism
  • Sensation of feeling full (abdominal distension during continuous ambulatory peritoneal dialysis [CAPD])

Assessment (Dx)
·         Auscultate bowel sounds. Reduced or hypoactive bowel sounds may be a sign of reduced gastric motility and constipation due  to low fluid intake, poor food choices, reduced activity, and hypoxemia.

·         Evaluate capability to masticate, taste, and swallow. Lesions of the mouth, throat, and esophagus and metallic or other taste alterations produced by medications may produce dysphagia, preventiving patient’s capacity to take food and lessening desire to eat.

·         Evaluate nutritional condition frequently, throughout every day nursing care, taking note of energy level; state of skin, nails, hair, oral cavity; craving to eat or anorexia. Gives the chance to examine differences from normal patient baseline, and affects choice of interventions.

  • Get nutritional history; incorporate family, significant others, or caregiver in evaluation. Patient’s awareness of actual intake may vary.

·         Observe muscle mass or subcutaneous fat as specified. If available,, Indirect calorimetry, may be helpful in more precisely approximating body reserves or losses and efficiency of therapy.

  • Record actual weight; do not approximate. Patients may be unconscious of their actual weight or weight loss because of approximation of weight.

  • Review abdomen, noting incidence or character of bowel sounds, abdominal distention, and reports of nausea. Gastric distention and intestinal atony are often present, leading in lowered or absent bowel sounds. Coming back of bowel sounds and liberation of symptoms indicates promptness for discontinuation of gastric aspiration.

1.         Any weight gain in the last 6 months? No__ Yes__ Amount: ___________
2.         Any weight loss in the last 6 months? No__ Yes__ Amount:____________
3.         How would you describe your appetite? Good__ Fair__ Poor__
4.         Do you have any food intolerance? No__ Yes__ Describe: ____________
5.         Do you have any dietary restrictions? (Check for those that are a part of a prescribed             regimen as well as those that patient restricts voluntarily, for example, to prevent flatus)             No__ Yes__ Describe: ___________________
6.         Describe an average day’s food intake for you (meals and snacks): _____
7.         Describe an average day’s fluid intake for you. _____________________
8.         Describe food likes and dislikes. _________________________________
9.         Would you like to: Gain weight?__ Lose weight?__ Niether__
10.        Any problems with:
            .           Nausea: No__ Yes__ Describe: _______________________________
            .           Vomiting: No__ Yes__ Describe: ______________________________
            .           Swallowing: No__ Yes__ Describe: ____________________________
            .           Chewing: No__ Yes__ Describe: ______________________________
            .           Indigestion: No__ Yes__ Describe: ____________________________
11.        Would you describe your usual lifestyle as: Active__ Sedate__

For breastfeeding mothers only:
12.        Do you have any concerns about breast feeding? No__ Yes__ Describe:
13.        Are you having any problems with breastfeeding? No__ Yes__ Describe:

1.         Skin examination
            a.         Warm__ Cool__ Moist__ Dry__
            b.         Lesions: No__ Yes__ Describe: _______________________________
            c.         Rash: No__ Yes__ Describe: _________________________________
            d.         Turgor: Firm__ Supple__ Dehydrated__ Fragile__
            e.         Color: Pale__ Pink__ Dusky__ Cyanotic__ Jaundiced__ Mottled__             Other____________________________________________________

2.         Mucous Membranes
            a.         Mouth
                        i.          Moist__ Dry__
                        ii.          Lesions: No__ Yes__ Describe: __________________________
                        iii.         Color: Pale__ Pink__
                        iv.         Teeth: Normal__ Abnormal__ Describe:____________________
                        v.         Dentures: No__ Yes__ Upper__ Lower__ Partial__
                        vi.         Gums: Normal__ Abnormal__ Describe:____________________
                        vii.        Tongue: Normal__ Abnormal__ Describe:___________________
            b.         Eyes
                        i.          Moist__ Dry__
                        ii.          Color of conjunctiva: Pale__ Pink__ Jaundiced__
                        iii.         Lesions: No__ Yes__ Describe:___________________________

3.         Edema
            a.         General: No__ Yes__ Describe:_______________________________
                        Abdominal girth: ___inches
            b.         Periorbital: No__ Yes__ Describe:_____________________________
            c.         Dependent: No__ Yes__ Describe:_____________________________
                        Ankle girth: Right:__ inches; Left__inches
4.         Thyroid: Normal__ Abnormal__ Describe: _________________________
5.         Jugular vein distention: No__ Yes__
6.         Gag reflex: Present__ Absent__
7.         Can patient move easily (turning, walking)? Yes__ No__
                        Describe limitations: __________________________________________
8.         Upon admission, was patient dressed appropriately for the weather?
                        Yes__ No__ Describe: ________________________________________

For breastfeeding mothers only:
9.         Breast exam: Normal__ Abnormal__ Describe:______________________
10.        If mother is breastfeeding, have infant weighed. Is infant’s weight within normal limits?             Yes__ No__

  • Establish etiological factors for diminished nutritional intake. Correct evaluation guides intervention. For example, patients with dentition problems need referral to a dentist, while patients with memory losses may need services such as Meals-on-Wheels.

  • Observe or discover manners toward eating and food. Various psychological, psychosocial, and cultural factors conclude the type, quantity, and aptness of food consumed.

  • Persuade patient partaking in recording food intake utilizing a daily log. Establishing of type, quantity, and pattern of food or fluid ingestion is aided by precise recording by patient or caregiver as the intake happens; memory is inadequate.

  • Watch environment in which eating takes place. Smaller number families nowadays have a general meal together. A lot of adults find themselves "eating on the run" or relying heavily on fast foods with lower nutritional components.

  • Review laboratory values that signifies nutritional health or worsening:
    1. Serum albumin. This shows degree of protein reduction (2.5 g/dl signifies severe diminution; 3.8 to 4.5 g/dl is normal).
    2. Transferrin. This is significant for iron transfer and typically diminishes as serum protein lowers.
    3. RBC and WBC counts. These are frequently lowered in malnutrition, showing anemia and reduced resistance to infection.
    4. Serum electrolyte values. Potassium is classically elevated and sodium is classically lowered in malnutrition.
shows nutritional condition and organ function, and signifies replacement needs. Note: Nutritional tests can be changed because of disease processes and reaction to a number of medications or therapies. (Various medications are metabolized by the liver and have possible for synergistic harm.)

·         Document ongoing caloric intake. Establshes necessitate for supplements or alternative feeding techniques.

  • Weigh patient weekly. During aggressive nutritional support, patient can gain up to 0.5 pound per day.

Therapeutic Interventions (Tx)
·         Administer medications between meals (if tolerated) and minimize fluid intake with meals, except fluid has nutritional value. Gastric fullness reduces appetite and food ingestion.

  • Advocate rest before meals. Calms down peristalsis and boosts available energy for eating. Helps out save energy, particularly when metabolic requirements are augmented by fever.

·         Arrange diet with patient or significant other, suggestive of foods from home if suitable. Offer small, frequent meals or snacks of nutritionally dense foods and nonacidic foods and beverages, with preference of foods appetizing to patient. Persuade high-calorie or nutritious foods, a number of of which may be considered appetite stimulants. Note time of day when appetite is finest, and aim to serve bigger meal at that time. Counting patient in planning provides sense of control of surroundings and may improve intake. Satisfying cravings for noninstitutional food may also enhance intake. Note: In this population, foods with a higher fat content may be suggested as tolerated to improve taste and oral ingestion.

  • Ask dietitian for further evaluation and suggestions regarding food partialities and nutritional assistance. Dietitians have a broader knowledge of the nutritional value of foods and may be useful in evaluating specific ethnic or cultural foods.

·         Avoid food(s) that provoke nausea or vomiting or are poorly tolerated by patient because of mouth sores or dysphagia. LImit serving very hot liquids or foods. Dish up foods that are easy to swallow. Pain in the mouth or fear of irritating oral lesions may lead the patient to be unwilling to eat. These actions may be helpful in escalating food intake.

  • Build up and persuade a pleasing milieu for meals. Dish up foods in well-ventilated, pleasing environment, with unhurried ambiance, friendly company. Pleasing milieu helps in lowering stress and is more favorable to eating. Encourages socialization and maximizes patient comfort when eating difficulty cause discomfiture.

·         Eliminate existing noxious environmental stimuli or situations that provokes gag reflex. Diminishes stimulus of the vomiting center in the medulla.

  • Encourage family to take food from home as fitting for hospitalized patients. Patients with specific ethnic, religious partialities or restrictions may not be able to consume hospital foods.

·         Give enteral or parenteral feedings as indicated. Enteral feedings are ideal because they cost less and carry less risk of aggravating endocrine dysfunction than TPN. Nevertheless, TPN may be necessary when oral or enteral feedings are not endured. TPN is set aside for those whose gut cannot take in even an elemental formula (such or those with severe refractory diarrhea.

·         Give frequent mouth care, noting secretion precautions. Prevent us of  alcohol-containing mouthwashes. Lowers discomfort related with nausea orvomiting, oral lesions, mucosal dryness, and halitosis. Clean mouth may improve appetite.

  • Give multivitamins, together with ascorbic acid (vitamin C), folic acid, vitamins B6 and D, and iron supplements, as ordered. Restores vitamin or mineral insufficiencies resulting from malnutrition/anemia or lost during dialysis.

·         Give nutritional solutions at ordered rate via infusion control device as required. Regulate rate to deliver ordered hourly intake. Do not raise rate to “catch up” if infusion slows. Nutrition support orders are based on individually estimated caloric and protein necessities. A regular rate of nutrient administration guarantees correct utilization with fewer side effects, such as hyperglycemia or dumping syndrome. Note: Constant and cyclic infusion of enteral formulas are usually better tolerated than bolus feedings and result in enhanced absorption.

·         Give small, frequent feedings; include patient likes or dislikes in meal preparation as much as possible, and incorporate “home foods,” as fitting. May improve patient’s craving for food and quantity of intake.

  • Institute fitting short- and long-range goals. Depending on the etiological factors of the problem, development in nutritional condition may take a long time. Without practical short-term goals to give tangible rewards, patients may be unable to find interest in addressing this problem.

  • Maintain patient on NPO as indicated. Resting the bowel reduces peristalsis and diarrhea, preventing malabsorption or loss of nutrients.

  • Offer a balanced diet of complex carbohydrates and planned quantity of high-quality protein and essential amino acids. Supplies adequate nutrients to enhance energy and avoid muscle wasting (catabolism); upholds tissue regeneration or healing, and electrolyte balance. Note: Fifty percent of protein ingestion should be derivative of protein sources with high biological value, such as the following: red meat, poultry, fish, and eggs.

  • Offer companionship during mealtime. Consideration to the social aspects of eating is significant in both the hospital and home settings.

·         Offer rest period before meals. Prevent stressful measures close to mealtime. Reduces fatigue; maximizes energy available for work of eating.

·         Patients require support/help to overcome underlying problems such as the following: anorexia, fatigue, muscular weakness. Permit sufficient time for mastication, swallowing, savoring food; offer socialization and feeding assistance as necessary.

  • Persuade use of seasoning for patients with alteration in sense of taste.

  • Propose ways to help patient with meals as required. Guarantee a pleasant milieu, make possible correct position, and offer good oral hygiene and dentition. Elevating the head of bed 30 degrees helps in swallowing and lessens risk of aspiration.

  • Recommence or advance diet as ordered. For example, clear liquids succeeding to bland, low residue; then high-protein, high-calorie, caffeine-free, nonspicy, and low-fiber as ordered. Permits the intestinal tract to readjust to the digestive process. Protein is essential for tissue healing integrity. Low bulk reduces peristaltic reaction to meal. Note: Dietary procedures depend on patient’s state. In moderate disease, elemental enteral products may be administered to give nutrition without overstimulating the bowel. Patient with toxic colitis is NPO and placed on parenteral nutrition.

  • Refer to occupational therapist for adaptive devices for patients with physical impairments.

  • Talk about potential need for enteral or parenteral nutritional assistance with patient, family, and caregiver as appropriate. Enteral tube feedings are ideal for patients with a working GI tract. Feedings may be unremitting or intermittent (bolus). Parenteral nutrition may be designated for patients who cannot bear enteral feedings. Either solution can be customized to give necessary glucose, protein, electrolytes, vitamins, minerals, and trace elements. Fat and fat-soluble vitamins can also be given two or three times per week. These feedings may be utilized with in-hospital, long-term care, and sub acute care settings, as well as in the home.

Educative (Edx)
  • Evaluate and strengthen the following to patient or caregivers:
    1. The basic four food groups, as well as necessitate for particular minerals or vitamins. Patients may not be aware of what is included in a balanced diet.
    2. Significance of maintaining sufficient caloric intake; an typical adult (70 kg) requires 1800 to 2200 kcal per day; patients with burns, severe infections, or draining wounds may need 3000 to 4000 kcal per day
    3. Foods high in calories and protein that will enhance weight gain and nitrogen balance.

  • Assist patient or Significant Other build up nutritionally balanced home meal plans. Enhances awareness of individual requirement and importance of nutrition in healing and recovery process.

  • Avoid beverages that are caffeinated or carbonated. These may reduce appetite and result to early satiety.

  • Offer referral to community nutritional resources such as Meals-on-Wheels or hot lunch programs for seniors as necessary.

  • Persuade exercise or as much physical activity as feasible. Metabolism and utilization of nutrients are improved by activity. May enhance appetite and general feelings of health.

  • Persuade patient to express feelings concerning recommencement of diet. Uncertainty to eat may be result of fear that food will lead to worsening of symptoms

·         Persuade patient to sit up for meals. Aids swallowing and decreases risk of aspiration.

  • Persuade small, frequent meals with foods high in protein and carbohydrates. Makes the most of nutrient intake without unnecessary fatigue or energy loss from eating large meals, and diminishes gastric irritation.

  • Persuade utilization of herbs or spices, such as the following: garlic, onion, pepper, parsley, cilantro, and lemon. Builds up appetite to food to help lower boredom with diet. Note: Some salt substitutes are high in K+, and regular soy sauce is high in Na+, and as a result, must to be avoided.

·         Persuade/help out with fine oral hygiene; before and after meals, use soft-bristled toothbrush for gentle brushing. Offer dilute, alcohol-free mouthwash if oral mucosa is ulcerated. Improves appetite and oral intake. Reduces bacterial growth, lessens potential for infection. Particular mouth-care methods may be required if tissue is sensitive/ulcerated/bleeding and pain is severe.


  1. nice blog great information

    Nutritional intervention is one of the key components of our scientific and holistic approach towards weight management and the associated medical conditions.

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