Nursing diagnosis: Risk for Imbalanced Nutrition: Less than Body Requirements
Altered ability to ingest nutrients—decreased LOC
Weakness of muscles required for chewing, swallowing
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Demonstrate maintenance of desired weight or progressive weight gain toward goal.
Experience no signs of malnutrition, with laboratory values within normal range.
Nursing intervention with rationale:
1. Assess ability to chew, swallow, cough, and handle secretions.
Rationale: These factors determine choice of feeding options because client must be protected from aspiration.
2. Auscultate bowel sounds, noting decreased or absent or hyperactive sounds.
Rationale: Gastrointestinal (GI) functioning is usually preserved in braininjured clients, so bowel sounds help in determining response to feeding or development of complications, such as ileus.
3. Weigh, as indicated.
Rationale: Evaluates effectiveness or need for changes in nutritional therapy.
4. Provide for feeding safety, such as elevate head of bed while eating or during tube feeding.
Rationale: Reduces risk of regurgitation and aspiration.
5. Divide feedings into small amounts and give frequently.
Rationale: Enhances digestion and client’s tolerance of nutrients and can improve client cooperation in eating.
6. Promote pleasant, relaxing environment, including socialization during meals. Encourage SO to bring in food that client enjoys.
Rationale: Although the recovering client may require assistance with feeding and use of assistive devices, mealtime socialization with SO or friends can improve intake and normalize the life function of eating.
7. Check stools, gastric aspirant, and vomitus for blood.
Rationale: Acute or subacute bleeding may occur (Cushing’s ulcer), requiring intervention and alternative method of providing nutrition.
8. Consult with dietitian or nutritional support team.
Rationale: Helps determine the client’s requirements for energy and to provide needed nutrients. Careful monitoring of nutrition indicators, such as weight and blood tests, are necessary to prevent problems associated with malnutrition—muscle wasting, pressure sores and decubitus ulcers, renal failure, atelectasis, and pneumonia.
9. Monitor laboratory studies, for example, prealbumin or albumin, transferrin, amino acid profile, iron, blood urea nitrogen (BUN), nitrogen balance studies, glucose, aspartate aminotransferase (AST) and alanine aminotransferase (ALT), and electrolytes.
Rationale: Identifies nutritional deficiencies, organ function, and response to nutritional therapy.
10. Administer feedings by appropriate means—IV, tube feeding, or oral feedings with soft foods and thick liquids.
Rationale: Choice of route depends on client needs and capabilities. Tube feedings (nasogastric, jejunostomy) may be required initially, or parenteral route may be indicated in presence of gastric or intestinal pathology. If client is able to swallow, soft foods or semiliquid foods may be more easily managed without aspiration.