Imbalanced Nutrition Nursing Care Plan
Imbalanced Nutrition Nursing Care Plan
Patient Information:
|
Name |
Age |
Diagnosis |
Date of Admission |
Room Number |
|---|---|---|---|---|
|
Edgar Spencer |
72 |
Chronic Heart Failure, Malnutrition |
March 15, 2050 |
102B |
Assessment Data:
|
Assessment Criteria |
Patient's Condition |
Nurse's Observations |
Date |
|---|---|---|---|
|
Appetite |
Loss of appetite, minimal food intake |
Patient reports reduced hunger, unable to eat full meals |
March 16, 2050 |
|
Weight |
14% weight loss over 2 months |
Weight 120 lbs (down from 140 lbs) |
March 16, 2050 |
|
Dietary Intake |
Inadequate nutrition intake (skips meals) |
Consuming only small amounts of soft foods |
March 16, 2050 |
Nursing Goals:
|
Goal |
Interventions |
Expected Outcomes |
Timeline |
|---|---|---|---|
|
1. Improve Nutritional Intake |
- Provide small, frequent meals. |
Patient will increase food intake by 25%. |
March 20, 2050 |
|
2. Promote Weight Gain |
- Collaborate with dietitian to create high-protein, high-calorie meal plan. |
Patient will gain 2-3 lbs by next evaluation. |
April 10, 2050 |
|
3. Monitor Hydration Levels |
- Encourage fluid intake (e.g., water, soups). |
Patient will maintain adequate hydration. |
March 20, 2050 |
Nursing Interventions:
|
Intervention |
Rationale |
Evaluation |
Date |
|---|---|---|---|
|
1. Provide nutritional supplements |
Ensure patient receives sufficient calories and proteins. |
Patient reports better energy and improvement in appetite. |
March 18, 2050 |
|
2. Observe for signs of malnutrition |
Early identification of deficiencies helps to prevent further complications. |
Weight increase, improved skin condition. |
April 10, 2050 |
|
3. Educate patient and family about dietary needs |
Educating the patient and family ensures adherence to the meal plan and enhances compliance. |
Family reports increased involvement in meal planning. |
March 17, 2050 |
Evaluation:
|
Evaluation Criteria |
Nurse's Observations |
Next Steps |
Date |
|---|---|---|---|
|
Nutritional Intake Improvement |
Patient eating larger meals and consuming supplements. |
Continue small meals; reassess after 1 week. |
March 23, 2050 |
|
Weight Gain |
Patient has gained 1.5 lbs. |
Increase calorie intake further if needed. |
April 10, 2050 |
|
Hydration Status |
Patient reports increased fluid intake and fewer signs of dehydration. |
Continue fluid encouragement. |
March 23, 2050 |
Prepared by: [YOUR NAME]
Email: [YOUR EMAIL]
