Clustered Cues Rationale Rationale Evaluation Diagnosis Criteria Interventions Imbalanced Definition: Intake of nutrition: less nutrients insufficient to than body meet metabolic demands. The client will be Document client’s Useful in defining degree requirements able to verbalize nutritional status on or extent of problem and related to Malabsorption is the understanding on admission, noting appropriate choice of inability to absorb inability of the digestive the importance of skin turgor, current interventions. nutrients; system to absorb one or a balanced diet weight, and degree decreased more of the major by of weight loss, absorption; loss vitamins, minerals, and integrity of oral of appetite; lack nutrients. Interruptions in The client will be mucosa, of information; the complex digestive able to ability/inability to insufficient process may occur demonstrate swallow, presence of financial anywhere in the digestive changes in his bowel tones, history resources system and cause diet as of nausea/vomiting decreased absorption. manifested by or diarrhea. proper food Diarrhea, an abnormal selection. Ascertain client’s Helpful in identifying increase in the frequency usual dietary specific needs and and liquidity of the stool or The client will pattern, strengths. Consideration in daily stool weight or demonstrate likes/dislikes. of individual preferences volume, commonly occurs adequate weight may improve dietary when the contents move so gain. intake. rapidly through the intestine and colon that Determine the Psychological factors there is inadequate time for client’s attitude towards eating may the GI secretions to be towards eating. affect one person’s absorbed. appetite and also to know the client’s eating Malnutrition may be a habits. consequence of the Monitor I&O and Useful in measuring patient’s lifestyle, lack of weight periodically. effectiveness of knowledge about adequate nutritional and fluid nutrition and its role in support. health maintenance, lack of resources, or lack of Assess for allergies May affect dietary appetite because of to food. Monitor choices and identify coughing and mucus frequency, volume areas for problem solving production. and consistency of to enhance, intake and stools. utilization of nutrients.
Encourage and Helps conserve energy.
provide frequent rest periods.
Encourage/provide Reduces bad taste left
oral care before and from sputum or after respiratory medications used for treatments. respiratory treatments that can stimulate the vomiting center.
Encourage small Maximizes nutrient
frequent meals with intake without undue foods high in protein fatigue or energy and carbohydrates. expenditure from eating large meals, and reduces gastric irritation.
Encourage SO to Creates a more normal
bring foods from social environment home and to share during mealtime, and meals with client helps meet personal, unless cultural preferences. contraindicated.