Care Plan for Nutritional Status

Category / Primary Body System

• Nutritional / Gastrointestinal System

Problem

• Patient is at risk for significant weight loss due to nutritional status.

Goal

• Patient will not experience significant weight loss for 90 days.

Plan/Approach

1. Dietary Management

   • Provide diet as ordered
   • Monitor intake of meals
   • Offer a variety of food choices to encourage intake

2. Monitoring and Reporting

   • Weigh the patient weekly or as ordered by MD/RNP
   • Report any significant weight decline to MD/RNP immediately

3. Consultations and Support

   • Consult with a dietitian as needed

4. Medication and Laboratory Monitoring

   • Administer medications as ordered
   • Conduct lab tests as ordered

Rationale

1. Dietary Management

   • Providing a prescribed diet and monitoring meal intake helps ensure the patient receives adequate nutrition and identifies any eating difficulties early.
   • Offering a variety of food choices can increase appetite and food intake, helping to maintain weight.

2. Monitoring and Reporting

   • Regularly weighing the patient allows for early detection of weight loss, enabling timely interventions.
   • Prompt reporting of significant weight loss ensures that healthcare providers can adjust the care plan as needed to prevent further decline.

3. Consultations and Support

   • Dietitian consultations provide expert guidance on nutritional needs and dietary modifications to support weight maintenance and overall health.

4. Medication and Laboratory Monitoring

   • Administering prescribed medications ensures the management of any underlying conditions that may affect nutritional status.
   • Regular lab tests monitor the patient’s nutritional markers and overall health, guiding adjustments to the care plan.

Actions

1. Dietary Management

   • Provide the patient with meals according to the prescribed diet, ensuring it meets their nutritional needs and preferences.
   • Monitor and document the patient’s meal intake daily, noting any difficulties or refusals.
   • Offer a variety of food choices to stimulate appetite and cater to the patient’s preferences.

2. Monitoring and Reporting

   • Weigh the patient weekly or as ordered by MD/RNP, documenting the results and comparing them to baseline weights.
   • Report any significant weight loss (e.g., >5% of body weight) to the MD/RNP immediately for further evaluation and intervention.

3. Consultations and Support

   • Schedule and facilitate a dietitian consult to assess the patient’s nutritional needs and develop a tailored nutrition plan.
   • Follow dietitian recommendations to adjust the patient’s diet as needed to prevent weight loss.

4. Medication and Laboratory Monitoring

   • Administer prescribed medications on schedule, monitoring for any side effects that may impact nutritional status.
   • Collect and analyze lab samples as ordered, reviewing the results with the healthcare team to guide care decisions.