Nursing diagnosis: imbalanced Nutrition: Less than Body Requirements related to Failure to ingest or inability to digest food or absorb nutrients necessary for formation of normal RBCs
Possibly evidenced by
Weight loss or weight below normal for age, height, and build
Decreased triceps skinfold measurement
Changes in gums, oral mucous membranes
Decreased tolerance for activity, weakness, and loss of muscle tone
Desired Outcomes/Evaluation Criteria—Client Will
Demonstrate progressive weight gain or stable weight, with normalization of laboratory values.
Experience no signs of malnutrition.
Demonstrate behaviors or lifestyle changes to regain and maintain appropriate weight.
Nursing intervention with rationale:
1. Review nutritional history, including food preferences.
Rationale: Identifies deficiencies and suggests possible interventions. Note: Daily meal diary over period of time may be necessary to identify anemia related to nutrient deficiencies such as no meat in diet—iron and vitamin B12 deficiency, or few leafy vegetables in diet—folic acid deficiency.
2. Observe and record client’s food intake.
Rationale: Monitors caloric intake or insufficient quality of food consumption.
3. Weigh periodically as appropriate, such as weekly.
Rationale: Monitors weight loss and effectiveness of nutritional interventions.
4. Recommend small, frequent meals and between-meal nourishment.
Rationale: May reduce fatigue and thus enhance intake while preventing gastric distention. Use of Ensure, Isomil, or similar product provides additional protein and calories.
5. Suggest bland diet, low in roughage, avoiding hot, spicy, or very acidic foods, as indicated.
Rationale: When oral lesions are present, pain may restrict type of foods client can tolerate.
6. Have client record and report occurrence of nausea or vomiting, flatus, and other related symptoms, such as irritability or impaired memory.
Rationale: May reflect effects of anemias, such as hypoxia or vitamin B12 deficiency, on organs.
7. Encourage or assist with good oral hygiene before and after meals; use soft-bristled toothbrush for gentle brushing. Provide dilute, alcohol-free mouthwash if oral mucosa is ulcerated.
Rationale: Enhances appetite and oral intake. Diminishes bacterial growth, minimizing possibility of infection. Special mouth-care techniques may be needed if tissue is fragile, ulcerated, or bleeding and pain is severe.
8. Consult with dietitian.
Rationale: Aids in establishing dietary plan to meet individual needs.
9. Monitor laboratory studies, such as Hgb/Hct, blood urea nitrogen (BUN), prealbumin and albumin, protein, transferrin, serum iron, vitamin B12, folic acid, TIBC, and serum electrolytes.
Rationale: Evaluates effectiveness of treatment regimen, including dietary sources of needed nutrients.
10. Administer medications, as indicated, for example: Vitamin and mineral supplements, such as cyanocobalamin (vitamin B12), folic acid (Folvite), and ascorbic acid (vitamin C)
Rationale: Replacements needed depend on type of anemia and presence of poor oral intake and identified deficiencies.