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Imbalanced Nutrition: less than body requirements related to insufficient…
Imbalanced Nutrition: less than body requirements related to insufficient dietary intake as evidenced by insufficient intake, food aversion, and weight loss.
Patient Information
Caucasian Female
Admission Date: 08/08/2016
84 years old
Primary Medical Diagnosis: senile dementia, GERD, chronic constipation, recurrent UTIs, polyneuropathy, depression, anxiety, diarrhea, primary hypertension, and chronic pain syndrome
Supporting Assessment Data
Patient weight was 150lb and then dropped to 139lb in a period of two months. Patient generally refuses meals; eats less than 25% of plate brought into room for meals; states food upsets her stomach. Displays no interest in food.
Patient is at increased risk for skin break down related to poor nutrition and immobility
Patient is at an increased fall risk due to increased weakness as her nutrition does not meet her metabolic demands.
Patient Centered Outcome Statements
A. Patient will ingest 1900kcal/day, including 55g of protein per day
Offer oral nutritional supplements
Determine time of day when patient's appetite is at the highest and offer highest caloric meal at this time.
Encourage patient to eat small, well-balanced meals, and nutritious snacks
Create a food journal to monitor patient's intake.
B. Patient will not lose weight from 11/14/18 to 12/14/18 and will maintain her BMI of 21.
Educate patient on proper dietary requirements. Patient verbalizes and demonstrates selection of foods that will accomplish a termination of weight loss.
Schedule rest periods before meals in order for patient to maintain strength for eating.
Encourage fluid and fiber intake
Weigh patient weekly.