XIX. NCP - Imbalanced Nutrition

DATE/TIME/ CUES NEED NURSING OBJECTIVE NURSING EVALUATION
SHIFT DIAGNOSIS INTERVENTIONS

WITH RATIONALE
Subjective: Imbalanced After 5 days 1. Monitor the Goal partially
“nagdako ko, sige N nutrition: more nursing patient’s intake and met.
February 22, ra ko ug kaon. U than body interventions, output. After 8 hours of
2019 Mas ganado na ko T requirements the patient will nursing
7:00AM – mukaon karon .” R related to be able to Rationale interventions, the
3:00PM As verbalized by I antagonism of demonstrate A fluctuation in fluid patient was able
the patient T h1 receptors behaviors to volume of just 5- to:
Southern I recover and 10% can have an
Philippines O maintain adverse effect on
Medical N appropriate health (Large, 1. Patient A’s
Center – Objective: A Rationale: weight as 2005). A deficit in energy level has
Institute of L Antagonism of evidenced by: fluid volume is improved.
Psychiatry 1. Weight = 64 kg hypothalamic known as a
and 2. BMI = 26.0 M H1 receptors by 1. Improved negative fluid 2. Slowly taking
Behavioral 3. Noticeably E SGAs may time- energy level balance and, if fluid adequate number
Medicine slower gait. T dependently intake is greater of calories and
Shorter stride A affect the 2. Stable than output, the nutrients
length B hypothalamus- muscle mass body is in positive
O brainstem measurements fluid balance
L circuits to cause (Scales and 3. BMI within the
I weight gain by Pilsworth, 2008). normal level/
C stimulating
appetite and fat 2. Observe patient’s
P accumulation ability to eat (time
A but reducing involved, motor
T energy skills, visual acuity,
T expenditure. ability to swallow
E The H1 receptor various textures).
R and its
N downstream Rationale
signaling In patients who have
molecules could schizophrenia,
be valuable ability to eat (motor
targets for the aspects) are often
design of new than not affected.
compounds for Observing how the
treating SGA- patient’s would help
induced weight to identify other
gain/obesity. factors and provide
proper nursing
(Lewis, S. M., interventions
Dirksen, S. R.,
Heitkemper, M. 3. If patient lacks
M., endurance,
Bucher, L., schedule rest
& periods before
Harding, M. meals and open
(2015). Medical- packages and cut
surgical nursing: up food for client.
Assessment
and Rationale
management of Nursing assistance
clinical with activities of
problems. daily living (ADLs)
St. Louis, MO: will conserve the
Elsevier/Mosby) client’s energy for
. activities the client
values. Clients who
take longer than 1
hour to complete a
meal may require
assistance (Evans,
1992).
4. Observe for signs
of hypoglycemia:
changes in LOC,
cold and clammy
skin, rapid pulse,
hunger, irritability,
anxiety, headache,
lightheadedness,
shakiness.
Rationale
One of the
physiological side
effects of
antipsychotic drugs
is it increases insulin
secretion in the Beta
cells in the
pancreas. Increase
in insulin decreases
glucose level in the
blood therefore can
cause hypoglycemia
5. Auscultate bowel
sounds. Note
reports of
abdominal pain,
bloating, nausea,
vomiting of
undigested food.
Rationale
Indigestion causes
irritability and
discomforts to the
patients, decreasing
their appetite and
food intake.
Auscultation of
bowel sound helps
the health care
provider to assess
and determine the
patient’s gut status
6. Provide good oral
hygiene before and
after meals.
Rationale
Good oral hygiene
enhances appetite;
the condition of the
oral mucosa is
critical to the ability
to eat. The oral
mucosa must be
moist, with
adequate saliva
production to
facilitate and aid in
the digestion of food
(Evans, 1992).
7. Assist the patient

in passive ROM
exercises
Rationale
Assisting the patient
in passive ROM
exercises increases
blood circulation
level therefore
promotes tissue
perfusion.
8. Provide
appropriate food
textures for chewing
ease. Insert
dentures (only if
needed) before
meals.
Rationale
The bony structure
of jaws changes
over time, requiring
adjustment of
dentures.
9. Observe client's
relationship to food.
Attempt to separate
physical from
psychological
causes for eating
difficulty.
Rationale
It may be difficult to
tell if the problem is
physical or
psychological.
Refusing to eat may
be the only way the
client can express
some control, and it
may also be a
symptom of
depression (Evans,
1992)
Dependent Nursing
Interventions
Collaborative
Nursing
Interventions
10. Consult dietician

and/or physician for
further assessment
and
recommendation
regarding food
preferences and
nutritional support.
Rationale
Collaborating with
other members of
the health care
team, in this case
the dietician, may
reveal changes that
should be made in
the patient’s dietary
intake, and this is
also because they
have better
understanding and
may do further
assessment of other
food groups.

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DATE/TIME/ CUES NEED NURSING OBJECTIVE NURSING EVALUATION

SHIFT DIAGNOSIS INTERVENTIONS

7. Assist the patient

10. Consult dietician

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