Nutritional Status

Care Plan for Nutritional Status

Category / Primary Body System:

Nutrition and Metabolism

Problem:

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

Goal:

Patient will not have significant weight loss for 90 days.

Plan/Approach:

1. Diet Provision:

   • Step-by-Step Approach: Provide diet as ordered.
   • Rationale: Ensures the patient receives the necessary nutrients to maintain weight and health.

2. Meal Intake Monitoring:

   • Step-by-Step Approach: Monitor intake of meals.
   • Rationale: Helps to track the patient’s food consumption and identify any issues with appetite or food preferences.

3. Food Texture Adjustment:

   • Step-by-Step Approach: Offer food with appropriate texture to prevent choking.
   • Rationale: Ensures patient safety and encourages adequate intake.

4. Weight Monitoring:

   • Step-by-Step Approach: Measure weight weekly or as ordered by MD/RNP.
   • Rationale: Regular weight monitoring helps in early detection of significant weight loss.

5. Notification of Weight Decline:

   • Step-by-Step Approach: Notify MD/RNP of any significant weight decline.
   • Rationale: Early intervention can be implemented to address any underlying issues.

6. Dietitian Consultation:

   • Step-by-Step Approach: Consult dietitian as needed.
   • Rationale: Provides expert guidance on nutritional needs and adjustments to the diet plan.

7. Medication Administration:

   • Step-by-Step Approach: Administer medications as ordered.
   • Rationale: Medications may be needed to address underlying conditions affecting nutritional status.

8. Lab Monitoring:

   • Step-by-Step Approach: Check labs as ordered.
   • Rationale: Monitors the patient’s biochemical markers to assess nutritional status and detect any deficiencies.

Actions:

1. Diet Provision:

   • Staff will provide diet as ordered.

2. Meal Intake Monitoring:

   • Staff will monitor intake of meals.

3. Food Texture Adjustment:

   • Staff will offer food with appropriate texture to prevent choking.

4. Weight Monitoring:

   • Staff will measure weight weekly or as ordered by MD/RNP.

5. Notification of Weight Decline:

   • Staff will notify MD/RNP of any significant weight decline.

6. Dietitian Consultation:

   • Staff will consult dietitian as needed.

7. Medication Administration:

   • Staff will administer medications as ordered.

8. Lab Monitoring:

   • Staff will check labs as ordered.