Nursing care plan for undernourishment, malnutrition (adult)

Causes loss of appetite and interest in food due to disease-related symptoms, side effects of drug therapy, diets that do not match the patient’s taste, and weight loss associated with inadequate intake of nutrients and decreased nutritional intake. Say a possible condition.

<Nursing care plan>

Weight will be (  ) kg by (  )
Improvement of oral disorders and increased food intake
You can eat with minimal unpleasant irritation
Reduces anxiety and stress and increases appetite
Can (maintain) the amount of energy consumed (maintained)

Observation plan
1. Disease, treatment content
2. Presence or absence of allergies
3. Factors that prevent food intake
-Disorders of the feeding center (brain tumor, cerebral hemorrhage, cerebral infarction, etc.)
-Dysphagia (cerebrovascular accident, neuromuscular disorder, amyotrophic lateral sclerosis, muscular dystrophy, cerebral palsy, Parkinson’s disease, etc.)
-Nutrition absorption disorders (Crohn’s disease, ulcerative colitis, necrotizing enterocolitis, lactose intolerance, etc.)
4. Vital signs, awareness level
5. Test data (TP, Alb, serum transthyretin, serum transferrin, electrolyte, blood glucose level, WBC, CRP, urinary ketone, abdominal roentgen)
6. Meal content, meal form, presence or absence of taste
7. Appetite, food intake
8. Balance between required calories and calorie intake
9. Water intake status
10. Presence / absence and degree of dehydration (presence / absence of dry mouth, skin condition, urine volume, presence / absence of fatigue and weakness)
11. Weight, changes in weight
13. Presence or absence of edema
14. Defecation status, presence or absence of abdominal distension
15. Sleep status
16. Presence or absence of symptoms that interfere with food intake
-Presence or absence of pain in the oral cavity or when swallowing
-Presence or absence of nausea and vomiting, frequency of vomiting, nature and amount of vomiting
17. Dining environment
18. Posture when eating, head position and angle, body position and angle
19. Meal feeding behavior
20. Presence / absence and degree of trismus
21. Oral condition
22. Teeth condition, presence or absence of dentures, gingival condition
23. Tongue movement and condition
24. Chewing ability, swallowing ability
25. Accompanying symptoms due to dysphagia (swelling, coughing, aspiration, feeling of stuffiness, food residue, nausea, vomiting)
26. Facial expressions and behavior during and after meals
27. Thoughts on food

Care plan
1. Adjust the eating environment according to the patient’s condition
2. Adjust the diet according to the patient’s condition and taste
3. Consider the amount of meals, the number of meals, the adjustment of time, the form of meals, the place of meals, the use of self-help tools, etc. according to the patient’s condition.
4. Adjust your posture when eating before starting a meal
5. Ingenuity in case of nausea or vomiting
-Wait until nausea or vomiting subsides
-Choose cold, low-smelling foods
-Consider using antiemetics
6. Ingenuity when there is paralysis on the face or tongue
-Get chewed on the healthy side (in the case of caregiving, put food on the healthy side)
-Stretching the muscles around the oral cavity, gargle and oral care before meals to promote saliva secretion
7. Ingenuity when the movement of the tongue is impaired
-Use self-help tools to place food behind the oral cavity
-Position to supine or fuller position
8. Ingenuity when it is easy to swallow
-Adjust water to semi-solid (use thickener or thickener)
-Avoid foods that can cause dysphagia (dry foods, foods that fall apart, etc.)
-Get water ingested
9. Ingenuity when there is a tracheal cannula
-Adjust cuff pressure just before meals
-Suction before and after eating
10. Consider high-calorie predation when intake is low
11. Perform regular weight measurements
12. Control defecation
13. Manage infusions as directed by your doctor
14. Talk to a nutrition manager or nutrition support team (NST) when needed
15. Introducing social support

Education plan
1. Explain to eat slowly on your own base
2. Explain that meal contents and meal forms can be changed
3. Explain the required calories and nutrients
4. Explain what to do if you have nausea or vomiting (see C-P)
5. Explain how to devise when there is paralysis on the face or tongue (see C-P)
6. Explain the device when the tongue movement is impaired (see C-P)
7. Explain the device when it is easy to swallow (see C-P)
8. Explain how to devise when there is a tracheal cannula (see C-P)
9. Explain to your family that high-energy, high-protein, digestible foods are good
10. Explain that if you have difficulty eating at home, consult a medical professional.
11. Describe social support

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