Nursing diagnosis: imbalanced Nutrition: Less than Body Requirements related to Conditions that interfere with nutrient intake or increase nutrient need or metabolic demand—cancer and associated treatments, anorexia, surgical procedures, dysphagia, or decreased level of consciousness
Possibly evidenced by
Body weight 10% or more under ideal
Decreased subcutaneous fat or muscle mass, poor muscle tone
Changes in gastric motility and stool characteristics
Desired Outcomes/Evaluation Criteria—Client Will
Demonstrate stable weight or progressive weight gain toward goal, with normalization of laboratory values and no signs of malnutrition.
Nursing intervention with rationale:
1. Assess nutritional status continually during daily nursing care, noting energy level; condition of skin, nails, hair, oral cavity; and desire to eat.
Rationale: Provides the opportunity to observe deviations from normal client baseline and influences choice of interventions.
2. Weigh daily and compare with admission weight.
Rationale: Establishes baseline, aids in monitoring effectiveness of therapeutic regimen, and alerts nurse to inappropriate trends in weight loss or gain.
3. Document oral intake by use of 24-hour recall, food history, and calorie counts, as appropriate.
Rationale: Identifies imbalance between estimated nutritional requirements and actual intake.
4. Ensure accurate collection of specimens (urine and stool) for nitrogen balance studies.
Rationale: Inaccurate collection can alter test results, leading to improper interpretation of client’s current status and needs.
5. Administer nutritional solutions at prescribed rate via infusion control device, as needed. Adjust rate to deliver prescribed hourly intake. Do not increase rate to “catch up” if infusion slows.
Rationale: Nutritional support prescriptions are based on individually estimated caloric and protein requirements. A consistent rate of nutrient administration ensures proper utilization with fewer side effects, such as hyperglycemia or dumping syndrome. Note: Continuous and cyclic infusions of enteral formulas are generally better tolerated than bolus feedings and result in improved absorption.
6. Be familiar with electrolyte content of nutritional solutions.
Rationale: Metabolic complications of nutritional support often result from a lack of appreciation of changes that can occur because of refeeding—hyperglycemia, hyperosmolar nonketotic coma (HHNC), and electrolyte imbalances.
7. Schedule activities with adequate rest periods. Promote relaxation techniques.
Rationale: Conserves energy and reduces calorie needs.
8. Observe appropriate “hang” time of parenteral solutions per protocol.
Rationale: Effectiveness of IV vitamins diminishes and solution degrades after 24 hours.
9. Monitor fingerstick glucose per protocol, such as four times per day (JCAHO, 1997; Moghissi, 2009) during initiation of therapy.
Rationale: High glucose content of solutions may lead to pancreatic fatigue, requiring use of supplemental insulin to prevent hyperglycemic complications. Note: Fingerstick determination of glucose level is more accurate than urine testing because of variations in renal glucose threshold.
10. Assess GI function and tolerance to enteral feedings, knowing type of tube used, such as NG or small bowel. Note bowel sounds, reports of nausea and abdominal discomfort, presence of diarrhea or constipation, development of weakness, lightheadedness, diaphoresis, tachycardia, and abdominal cramping.
Rationale: Because protein turnover of the GI mucosa occurs approximately every 3 days, the GI tract is at great risk for early dysfunction and atrophy from disease and malnutrition. Intolerance of formula or presence of dumping syndrome may require alteration of rate of administration, concentration or type of formula, or possibly change to parenteral administration. Note: Use of postpyloric feeding tube eliminates need for active bowel sounds as a criterion for tolerance.