Altered Nutrition: Less Than Body Requirements Care Plan

Assessment

• Obtain a complete nutritional history, including dietary intake, eating habits, and food preferences.
• Perform a physical examination, including assessment of body weight, height, and body mass index (BMI).
• Review laboratory tests, including serum albumin, prealbumin, and hemoglobin levels.
• Assess for signs and symptoms of malnutrition, such as fatigue, weakness, and poor wound healing.

Diagnosis

• Altered nutrition: less than body requirements

Goals

• Maintain or improve nutritional status.
• Prevent or treat complications of malnutrition.
• Educate the patient and family about nutrition and healthy eating habits.

Interventions

Nutritional Support

• Provide oral supplements, such as protein shakes or meal replacement drinks.
• Use enteral nutrition (feeding through a tube into the stomach or small intestine) if the patient is unable to eat orally.
• Consider parenteral nutrition (feeding through a vein) if the patient is unable to tolerate enteral nutrition.

Dietary Counseling

• Educate the patient and family about the importance of good nutrition.
• Provide guidance on healthy eating habits, including increasing calorie and protein intake.
• Refer the patient to a registered dietitian for individualized nutrition counseling.

Medical Management

• Treat underlying medical conditions that may be contributing to malnutrition.
• Prescribe medications to improve appetite or absorption of nutrients.
• Monitor the patient’s nutritional status and adjust the care plan as needed.

Other Interventions

• Encourage the patient to eat in a pleasant environment.
• Offer small, frequent meals instead of large meals.
• Avoid giving the patient fluids before meals, as this can fill the stomach and reduce appetite.
• Provide emotional support and encouragement to the patient.

Evaluation

• Monitor the patient’s nutritional status, including body weight, BMI, and laboratory tests.
• Assess for signs and symptoms of malnutrition.
• Evaluate the patient’s understanding of nutrition and healthy eating habits.
• Make adjustments to the care plan as needed.

Documentation

• Document the patient’s nutritional assessment, diagnosis, goals, interventions, and evaluation.
• Include information about the patient’s dietary intake, eating habits, and food preferences.
• Note any signs and symptoms of malnutrition.
• Document the patient’s progress and any changes to the care plan.