Week 5 Nursing Diagnosis and Planning related to Nutrition – Flashcards

apply when there is an increased potential or vulnerability (risk) for a patient to develop a problem or complication, such as a risk for not getting adequate nutrition.

Risk nursing diagnosis = diagnosis label + risk factors

Risk for Imbalanced Nutrition: Less than Body Requirements with risk factors of chronic nausea and loss of appetite Risk for Aspiration with risk factor of difficulty swallowing secondary to facial paralysis

apply when there is an actual problem or complication, such as difficulty swallowing

Actual nursing diagnosis = diagnosis label + related factors + defining characteristics

Impaired Swallowing related to residual effects of neurologic damage secondary to cerebrovascular accident, as evidenced by gagging and choking with oral intake attempts Feeding: Self-Care Deficit related to sensory and motor deficits secondary to spinal cord injury, as evidenced by bilateral upper-extremity paralysis and an inability to self-feed

are used in situations in which the patient expresses interest in improving their health status through a positive change in behavior, such as desire to eat a healthier diet.

Health-promotion nursing diagnosis = diagnosis label + defining characteristics

Readiness for Enhanced Nutrition as evidenced by expression of desire for a balanced, healthy dietary intake and verbalization of American Diabetic Association nutritional guidelines Readiness for Enhanced Knowledge as evidenced by patient requesting written materials about healthy food choices

Nursing Diagnosis Risk for Aspiration with risk factor of difficulty swallowing secondary to facial paralysis Measurable Patient-Centered Goal Patient will not exhibit any signs or symptoms of aspiration during this hospitalization (e.g., lungs clear, respiratory rate within normal range for patient).

Nursing Diagnosis Feeding: Self-Care Deficit related to sensory and motor deficits secondary to spinal cord injury, as evidenced by bilateral upper-extremity paralysis and an inability to self-feed Measurable Patient-Centered Goal Patient will demonstrate the ability to use assistive devices for self-feeding before discharge.

Nursing Diagnosis Imbalanced Nutrition: Less than Body Requirements related to inadequate dietary intake, as evidenced by cachectic appearance and 40-lb weight loss in past 6 months Measurable Patient-Centered Goal Patient will gain 1 to 2 lbs each week until weight is within normal range.

Nursing Diagnosis Readiness for Enhanced Nutrition related to expression of desire for a balanced, healthy dietary intake and verbalization of American Diabetic Association nutritional guidelines Measurable Patient-Centered Goal Patient will demonstrate awareness of balanced, nutrient-rich food options for self-cooked meals by selecting these items from a list before discharge to home.

Patient-centered nutritional goals and dietary care plans are most effective if the patient's individual dietary preferences and cultural and religious nutritional needs are considered.

A registered dietitian is helpful in providing nutritional education and services that address the psychosocial and economic factors that impact nutrition.

Case managers are responsible for coordinating timely, cost-effective services such as provision of durable medical equipment, infusion therapy, transportation, and follow-up care after discharge.

Collaboration with a speech therapist is needed for patients who have impaired swallowing and/or require restorative therapy.

Collaboration with a board-certified psychologist may be necessary if psychological factors have an impact on the patient's recovery.

Assistance with feeding can be delegated to unlicensed assistive personnel (UAP). Registered nurses are responsible for supervising and guiding care provided by UAP to ensure patient safety.