Friday, November 26, 2010

Imbalanced Nutrition: More than Body Requirements

Imbalanced Nutrition: More than Body Requirements

NANDA Definition
Imbalanced nutrition: more than body requirements are the intake of nutrients that exceeds metabolic needs.

Discussion of the Problem
Imbalanced nutrition: more than body requirements refers to a caloric intake I excess of daily energy requirements, resulting in storage of energy in the form of adipose tissue. As the amount of stored fat increases, the individual becomes overweight or obese. A person is said to be overweight when BMI is between 25 and 29.9 kg/m2  and obese when BMI is >30 kg/m2 . Factors that affect weight gain include genetics, sedentary lifestyle, and emotional factors associated with dysfunctional eating. Medical conditions associated with this problem are as follows: diabetes mellitus, severe hypertension, and Cushing’s syndrome. Cultural or ethnic background also influences eating habits. Overall nutritional requirements of geriatric patients are similar to those of younger patients, except that calories should be reduced because of their leaner body mass. The major goals for this problem is to maintain or restore optimal nutrition status, promote healthy nutritional practices, prevent complication associated with malnutrition and decrease weight.

Nursing Interventions Classification (NIC)
  • Nutrition Counseling
  • Nutritional Monitoring
  • Weight Reduction Assistance

Nursing Outcomes Classification (NOC)
  • Nutritional Status: Food and Fluid Intake
  • Weight Control
  • Knowledge: Diet

Goal and Objectives
  • Patient will articulate actions essential to attain weight reduction.
·         Patient will cemonstrate change in eating patterns and participation in individual exercise program.
  • Patient will commence an appropriate program of exercise.
  • Patient will demonstrate proper selection of meals or menu planning toward the goal of weight reduction.
  • Patient will exhibit weight loss with optimal continuation of health.
·         Patient will recognize inappropriate behaviors and consequences related with overeating or weight gain.

Subjective and Objective data
  • Eating in response to external cues such as time of day or social situation
  • Eating in response to internal cues other than hunger
  • Reported or observed dysfunctional eating patterns intake more than body requirements
  • Triceps skin fold greater than 15 mm in men, 25 mm in women
·         Weight of 20% over ideal for height and frame ; excess body fat by skinfold/other measurements

Related Factors
  • Cultural preferences
  • Excessive intake in relation to metabolic need
  • Lack of knowledge of nutritional needs, food intake, and/or appropriate food preparation
  • Metabolic disorders
  • Poor dietary habits
·         Psychosocial factors
  • Sedentary lifestyle
·         Socioeconomic status
  • Use of food as coping mechanism

Assessment (Dx)
  • Assess for height and weight and calculate body mass index ratio. Body mass index (BMI) is the person’s weight in kilograms divided by the square of his or her height in meters. A BMI between 20 and 24 is associated with healthier outcomes but greater than 25 are associated with morbidity and mortality.

·         Assess individual cause for obesity, e.g., organic or nonorganic and risk factors in the family. Provides information for individualized care plan.

  • Determine body fat composition by skin fold measurements with the use of skin calipers. This provides more accurate estimation of body fats around skin folds.

  • Weigh individual periodically (do not estimate as much as possible) as indicated, and assess appropriate body measurements. Patients may be unaware of their actual weight. Provide weight measurement for accurate measurement.

  • Evaluate nutritional assessment. This includes types and amount of food, its preparation, intake pattern (e.g., time of day, frequency, and other activities patient does while eating). Provide information that will help patient modify inappropriate lifestyles.

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__

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:
a.         Nausea: No__ Yes__ Describe: _______________________________
b.         Vomiting: No__ Yes__ Describe: ______________________________
c.         Swallowing: No__ Yes__ Describe: ____________________________
d.         Chewing: No__ Yes__ Describe: ______________________________
e.         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:

  • Assess ability to accurately identify appropriate food portions with are essential and non essential for weight reduction. Serving sizes must be understood to limit intake according to a planned diet.

  • Assess ability to plan a menu, making appropriate food selections suitable for patients’ goal. Cultural, ethnic and even religious influences need to be identified and addressed.

  • Assess activities of daily living. Patients may be confusing routine activity with exercise necessary to enhance and maintain weight loss.

  • Assess and document effects or complications of being overweight to the patient. A medical complication that may arise from being overweight includes cardiovascular and respiratory dysfunction, higher incidence of diabetes mellitus, and aggravation of musculoskeletal disorders.

  • Assess current activity levels and plan progressive exercise program (e.g., walking, jogging, and stretching) tailored to the individual’s goals and choice. Exercise encourages further weight loss by reducing appetite; increasing energy; toning muscles; and enhancing cardiac fitness, sense of well-being, and accomplishment.

  • Assess the importance and meaning of food for the patient. When food is used as a coping mechanism or as a self-reward, the emotional needs being met by intake of food will need to be addressed as part of the overall plan for weight reduction.

  • Evaluate ability to read food labels. Stress to patient the importance of understanding that "low-fat" or "fat-free" does not mean that a food item is calorie-free.

Therapeutic Interventions (Tx)
·         Educate patient on appetite plan programs. Patient must identify signals of hunger and fullness that are often are not recognized.

·         Encourage implementation of daily food diary, e.g., caloric intake, types and amounts of food, eating habits. Provides the opportunity for the individual to focus on/internalize a realistic picture of the amount of food ingested and corresponding eating habits/feelings.

  • Encourage patient to keep a daily log of food or liquid ingestion and caloric intake. Memory is inadequate for quantification of intake, and a visual record may also help patient to make more suitable food choices and serving sizes.

  • Encourage water intake. Water assists in the excretion of byproducts of fat breakdown and helps prevent ketosis.

  • Establish an appropriate short-term and long-term goal. One pound of adipose tissue contains 3500 kcal. The patient must have a calorie deficit of 500 kcal/day enable to lose 1 pound/week. Reasonable weight loss (1–2 lb/wk is considered normal) results in more lasting effects.

  • Implement calorie intake appropriate for body type and lifestyle. Modification of diet that involves changing patterns that have been firmly established by culture, family, and personal factors.

·                   stress the importance of appropriate food selections, such as a diet rich in fruits, vegetables, and low-fat dairy foods referred to as the DASH Dietary Approaches to Stop Hypertension) diet and avoiding foods high in saturated fats and cholesterol (fatty meat, egg yolks, whole dairy products, shrimp, organ meats). Avoiding foods high in saturated fat and cholesterol is important in preventing progressing atherogenesis. Moderation and use of low-fat products in place of total abstinence from certain food items may prevent sense of deprivation and enhance cooperation with dietary regimen.

  • Encourage patients’ awareness  regarding nutritional habits that may contribute to or prevent overeating:
    1. To realize the time needed for eating. Hurried eating may result in overeating.
    2. Avoid other diversional activities while eating (e.g., reading, television viewing, or telephoning). Provides more time for eating than on other things.
    3. Observe for cues that lead to eating poorly (e.g., odor, time, depression, or boredom). Suggest alternative ways on prior to mealtime.
    4. Eat in a designated place (e.g., at the table rather than in front of the television). This prevents and controls environmental stimuli for eating and other impulse eating.
    5. Recognize actual hunger and desire to eat. Eating when not hungry is a commonly recognized symptom among overeaters.

  • Consult dietitian for further assessment and recommendations regarding a weight loss program. Changes in eating patterns are required for weight loss. A professional should be considered when planning weight loss programs.

  • Encourage exercise as tolerated by patient. Exercise is an integral part of weight reduction programs. The combination of diet and exercise promotes loss of adipose tissue rather than lean tissue.

  • Include behavior modification strategies. Education as the sole intervention is unlikely to achieve and maintain weight loss.

  • Promote good attitude towards eating and exercise by positive reinforcement as indicated. Encourage patients self confidence on what has been accomplished.

Educative (Edx)
·         Discuss the need to give self permission to include desired/craved food items in dietary plan. Denying self by excluding desired/favorite foods results in a sense of deprivation and feelings of guilt/failure. Such feelings may hinder the weight loss program.

  • Include family and significant others in the nutrition counseling. Success rates are higher when the family incorporates a healthy eating plan.

  • Provide information for patient about pharmacological agents such as appetite suppressants that can aid in weight loss. These drugs aid in weight reduction by acting chemically to alter the patient’s desire to eat.

  • Refer patient to commercial weight-loss program if not medically contraindicated. Some individuals require the regimented approach or ongoing support during weight loss, whereas others are able (and may prefer) to manage a weight-loss program independently.

  • Remind patient that significant weight loss requires a long period. Constant reminding encourages patient to stick with the weight loss program.

·         Stress the importance of avoiding fad diets. Elimination of needed components can lead to metabolic imbalances, e.g., excessive reduction of carbohydrates can lead to fatigue, headache, instability/weakness, and metabolic acidosis (ketosis).

·         Stress the importance of avoiding tension or anxiety at mealtimes and not eating too quickly. Reducing tension provides a more relaxed eating atmosphere for the patient and encourages more leisurely eating patterns.

·         Watch out and be alert for signs of binge eating and develop strategies for dealing with these episodes, e.g., substituting other actions for eating. The patient who binges experiences guilt about it.

  • Review and reinforce knowledge regarding the following:
    1. Food pyramid
    2. Proper and adequate serving sizes
    3. Caloric content of food.
    4. Methods of food preparation, such as substituting baking and grilling for frying foods

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