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 |
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