NANDA Definition: Intake of nutrients insufficient to meet metabolic needs
Adequate nutrition is necessary to meet the body’s demands. Nutritional status can be affected by disease or injury states (e.g., gastrointestinal [GI] malabsorption, cancer, burns); physical factors (e.g., muscle weakness, poor dentition, activity intolerance, pain, substance abuse); social factors (e.g., lack of financial resources to obtain nutritious foods); or psychological factors (e.g., depression, boredom). During times of illness (e.g., trauma, surgery, sepsis, burns), adequate nutrition plays an important role in healing and recovery. Cultural and religious factors strongly affect the food habits of patients. Women exhibit a higher incidence of voluntary restriction of food intake secondary to anorexia, bulimia, and self-constructed fad dieting. Patients who are elderly likewise experience problems in nutrition related to lack of financial resources, cognitive impairments causing them to forget to eat, physical limitations that interfere with preparing food, deterioration of their sense of taste and smell, reduction of gastric secretion that accompanies aging and interferes with digestion, and social isolation and boredom that cause a lack of interest in eating. This care plan addresses general concerns related to nutritional deficits for the hospital or home setting.
* Defining Characteristics: Loss of weight with or without adequate caloric intake
* 10% to 20% below ideal body weight
* Documented inadequate caloric intake
* Related Factors: Inability to ingest foods
* Inability to digest foods
* Inability to absorb or metabolize foods
* Inability to procure adequate amounts of food
* Knowledge deficit
* Unwillingness to eat
* Increased metabolic needs caused by disease process or therapy
* Expected Outcomes Patient or caregiver verbalizes and demonstrates selection of foods or meals that will achieve a cessation of weight loss.
* Patient weighs within 10% of ideal body weight.
* Document actual weight; do not estimate. Patients may be unaware of their actual weight or weight loss due to estimating weight.
* intervObtain nutritional history; include family, significant others, or caregiver in assessment. Patient’s perception of actual intake may differ.
* Determine etiological factors for reduced nutritional intake. Proper assessment guides intervention. For example, patients with dentition problems require referral to a dentist, whereas patients with memory losses may require services such as Meals-on-Wheels.
* Monitor or explore attitudes toward eating and food. Many psychological, psychosocial, and cultural factors determine the type, amount, and appropriateness of food consumed.
* Monitor environment in which eating occurs. Fewer families today have a general meal together. Many adults find themselves "eating on the run" (e.g., at their desk, in the car) or relying heavily on fast foods with reduced nutritional components.
* Encourage patient participation in recording food intake using a daily log. Determination of type, amount, and pattern of food or fluid intake is facilitated by accurate documentation by patient or caregiver as the intake occurs; memory is insufficient.
* Monitor laboratory values that indicate nutritional well-being/deterioration:
o Serum albumin This indicates degree of protein depletion (2.5 g/dl indicates severe depletion; 3.8 to 4.5 g/dl is normal).
o Transferrin This is important for iron transfer and typically decreases as serum protein decreases.
o RBC and WBC counts These are usually decreased in malnutrition, indicating anemia and decreased resistance to infection.
o Serum electrolyte values Potassium is typically increased and sodium is typically decreased in malnutrition.
* Weigh patient weekly. During aggressive nutritional support, patient can gain up to 0.5 pound/day.
* Consult dietitian for further assessment and recommendations regarding food preferences and nutritional support. Dietitians have a greater understanding of the nutritional value of foods and may be helpful in assessing specific ethnic or cultural foods (e.g., "soul foods," Hispanic dishes, kosher foods).
* Establish appropriate short- and long-range goals. Depending on the etiological factors of the problem, improvement in nutritional status may take a long time. Without realistic short-term goals to provide tangible rewards, patients may lose interest in addressing this problem.
* Suggest ways to assist patient with meals as needed. Ensure a pleasant environment, facilitate proper position, and provide good oral hygiene and dentition. Elevating the head of bed 30 degrees aids in swallowing and reduces risk of aspiration.
* Provide companionship during mealtime. Attention to the social aspects of eating is important in both the hospital and home settings.
* For patients with changes in sense of taste, encourage use of seasoning.
* For patients with physical impairments, refer to occupational therapist for adaptive devices.
* For hospitalized patients, encourage family to bring food from home as appropriate. Patients with specific ethnic, religious preferences, or restrictions may not be able to eat hospital foods.
* Suggest liquid drinks for supplemental nutrition.
* Discourage beverages that are caffeinated or carbonated. These may decrease appetite and lead to early satiety.
* Discuss possible need for enteral or parenteral nutritional support with patient, family, and caregiver as appropriate. Enteral tube feedings are preferred for patients with a functioning GI tract. Feedings may be continuous or intermittent (bolus). Parenteral nutrition may be indicated for patients who cannot tolerate enteral feedings. Either solution can be modified to provide required glucose, protein, electrolytes, vitamins, minerals, and trace elements. Fat and fat-soluble vitamins can also be administered two or three times per week. These feedings may be used with in-hospital, long-term care, and subacute care settings, as well as in the home.
* Encourage exercise. Metabolism and utilization of nutrients are enhanced by activity.
Education/Continuity of Care
* Review and reinforce the following to patient or caregivers:
o The basic four food groups, as well as the need for specific minerals or vitamins Patients may not understand what is involved in a balanced diet.
o Importance of maintaining adequate caloric intake; an average adult (70 kg) needs 1800 to 2200 kcal/ day; patients with burns, severe infections, or draining wounds may require 3000 to 4000 kcal/day
o Foods high in calories and protein that will promote weight gain and nitrogen balance (e.g., small frequent meals of foods high in calories and protein)
* Provide referral to community nutritional resources such as Meals-on-Wheels or hot lunch programs for seniors as indicated.