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Obesity Nursing Care Plan (NCP)

Obesity is defined as an excess accumulation of body fat at least 20% over average weight for age, sex, and height. Although considered to be a type of eating disorder, obesity is a general medical condition coded on Axis III, with psychological factors that adversely affect the course and treatment of the medical condition, creating additional health risks for the individual.

DSM-IV
316.00 Psychological factors affecting medical condition—maladaptive health behaviors

ETIOLOGICAL THEORIES
Psychodynamics
Food is substituted by the parent for affection and love. The child harbors repressed feelings of hostility toward the parent, which may be expressed inward on the self. Because of a poor self-concept, the person has difficulty with other relationships. Eating is associated with a feeling of satisfaction and becomes the primary defense.

Biological
These disorders may arise from neuroendocrine abnormalities within the hypothalamus, which cause various chemical disturbances. Familial tendencies have been identified, but obesity is not clearly identified as being hereditary. People who are overweight have more fat cells than thin people and are known to be less active. Although overeating has long been believed to be the cause of obesity, research has not borne this out. Another popular theory has identified carbohydrates as the fattening substance. Currently, a high intake of fat in the diet is being identified as the reason for weight gain/inability to lose weight. The setpoint theory proposes that people are programmed to maintain a certain level of weight to protect fat stores. Studies reveal that leptin regulates body weight by telling the body how much fat is being stored. Obese individuals often have higher leptin levels, suggesting a failure of the body to respond to leptin. This may represent a deficiency of receptor sites or inadequate amounts of glucagon-like peptide-1 (GPL-1), which may impair the leptin signaling pathway.

In recent research, genetics, metabolic changes placing some people at risk, and the way the body stores fat all play a part in the problems of obesity. Rather than a single, simple cause, obesity appears to be the result of a complex system reflecting all these factors.

Family Dynamics
Parents act as role models for the child. Maladaptive coping patterns (overeating) are learned within the family system and are supported through positive (or even negative) reinforcement. Family systems may sabotage efforts at changing any part of the system to maintain the status quo.

NURSING PRIORITIES
1. Help client identify a workable method of weight control incorporating needed nutrients/healthful foods.
2. Promote improved self-concept, including body image, self-esteem.
3. Encourage health practices to provide for weight control throughout life.

DISCHARGE GOALS
1. Healthy pattern for eating and weight control identified.
2. Weight loss toward desired goal established.
3. Positive perception of self verbalized.
4. Plan in place to meet needs for future weight-control.

Nursing diagnosis for obesity: Altered Nutrition, More than Body Requirements may be related to Food intake that exceeds body needs; Psychosocial factors; and Socioeconomic status possibly evidenced by Weight of 20% or more over optimum body weight; excess body fat by anthropometric measurements; Reported/observed dysfunctional eating patterns; intake more; than body requirements.

Desired Outcomes:
1. Identify inappropriate behaviors and consequences associated with overeating or weight gain.
2. Demonstrate change in eating patterns and involvement in individual exercise program.
3. Display weight loss with optimal maintenance of health.

Nursing intervention with rationale:
1. Review individual factors for obesity (e.g., organic or nonorganic).
Rationale: Identifies/influences choice of interventions.

2. Implement/review daily food diary (e.g., caloric intake, types of food, eating habits).
Rationale: Provides the opportunity for the individual to focus on/internalize a realistic picture of the amount of food ingested and corresponding eating habits/feelings. Identifies patterns requiring changes and/or a base on which to tailor the dietary program.

3. Discuss emotions/events associated with eating.
Rationale: Helps to identify when client is eating to satisfy an emotional need rather than physiological hunger.

4. Formulate an eating plan with the client.
Rationale: Although there is no basis for recommending one diet over another, a good reducing diet should contain foods from all food groups with a focus on low-fat intake. It is helpful to keep the plan as similar to client’s usual eating pattern as possible. A plan developed with and agreed to by the client is more apt to be successful. Note: It is important to maintain adequate protein intake to prevent loss of lean muscle mass.

5. Develop nutritional plan using knowledge of individual’s height, body build, age, gender, individual patterns of eating, and energy and nutrient requirements.
Rationale: Standard tables are subject to error when applied to individual situations, and circadian rhythms / lifestyle patterns need to be considered.

6. Emphasize the importance of avoiding fad diets.
Rationale: Elimination of needed components can lead to metabolic imbalances (e.g., excessive reduction of carbohydrates can lead to fatigue, headache, instability and weakness, and metabolic acidosis [ketosis] interfering with effectiveness of weight loss program).

7. Discuss need to give self permission to include desired/craved food items in dietary plan.
Rationale: Denying self by excluding desired/favorite foods results in a sense of deprivation and feelings of guilt/failure when individual succumbs to temptation. These feelings can sabotage weight loss. Knowing that it is important to include small portions of these foods can prevent negative feelings and promote cooperation with weight loss program.

8. Reassess caloric requirements every 2–4 weeks to determine need for adjustment. Be aware of plateaus when weight remains stable for periods of time.
Rationale: Changes in weight and exercise will necessitate changes in diet. As weight is lost, changes in metabolism occur. Plateaus can create distrust and accusations of “cheating” on caloric intake, which are not helpful. Client may need additional support at this time.

9. Consult with dietitian to determine caloric/nutrient requirements for individual weight loss.
Rationale: Individual intake can be calculated by several different formulas, but weight reduction is based on the basal caloric requirement for 24 hours, depending on client’s sex, age, current/desired weight, and length of time estimated to achieve desired weight.

10. Provide medications as indicated: Appetite-suppressant drugs, e.g., diethylpropion (Tenuate), mazindol (Sanorex).
Rationale: May be used with caution/supervision at the beginning of a weight loss program to support client during stress of behavioral/lifestyle changes. They are only effective for a few weeks and may cause problems of tolerance/dependence in some people.
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