1) imbalanced nutrition:less than body requirements r/t inability to ingest food(lack of appetite) aeb weight loss
: nutrition meets metabolic demands outcome
: client will demonstrate that nutrition meets metabolic demands aeb weight gain of 1 or more pounds during hospitilization. interventions
: 1)obtain weights using same scale, same time of day, and same clothing, as much as possible. 2) medicate for pain nausea and manage side effects.
goal is not measurable or time specific. outcome is not reasonable. in how many days should a 1 pound weight gain happen? i really don't know, but you should state something. i do know that it takes 3500 calories to = a pound. that would be in addition to the daily calorie intake required to sustain the person's current weight.
how is "medicate for pain nausea and manage side effects" treating the patient for the weight loss? that makes no sense. determine if one reason why he is losing weight is because is daily calorie intake is too low and then boost it up. give him foods he likes. send him 6 meals a day instead of 3.
should i also list abdominal cramping/pain, nausea, diarrhea, increased flatulence in my r/t factors? is lack of appetite considered inability to ingest?
related factors are the etiology, or underlying cause, of the problem (nursing diagnosis). imbalanced nutrition: less than body requirements is the intake of nutrients insufficient to meet metabolic needs. diarrhea and flatulence do not cause a reduced intake of food. abdominal pain is specifically listed as a defining characteristic (symptom) for this diagnosis so it is not a related factor either. nausea you can use. lack of appetite sounds the same as a lack of interest in food and an aversion to eating which are both defining characteristics (symptoms) for this diagnosis so it cannot be a related factor either.
better: imbalanced nutrition: less than body requirements r/t nausea aeb weight loss of 10# without effort recently, lack of appetite, hypogastric region pain, "crampy feeling" in lower abdomen for the past 2 wks, increased gas and diarrhea
2) risk for falls r/t history of falls, over age 65, diarrhea and fatigue
: remain free from falls outcome
:client will demonstrate lifestyle changes to reduce risk factors and protect self from injury aeb no report of falls during hospitilization interventions
: 1)assess mood, coping abilities, personality styles 2) provide/instruct in use of mobility devices and safety devices, like grab bars and call light/personal assistance systems.
this patient has orthostatic hypotension (b/p drops when he stands up) and that is a risk factor for falls as well.
better: risk for falls r/t orthostatic hypotension, history of falls, over age 65, diarrhea and fatigue.
i would add:
- risk for deficient fluid volume r/t gi bleeding