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Nutritional Status

Care Plan

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.
Tags
Nutritional Status
Nutritional care
Weight Monitoring
Diet Management
Patient Safety
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