Nursing dx question

[sparklie.lady]

So....I have a patient with FAP who is in for her 22nd GI surgery. I've covered the big issues, pain & anxiety in other diagnostic statements, but I'm stuck on this one. It appears to me that imbalanced nutrition is a big problem for this lady. Her labs are borderline normal-low, she has lost (by her claim) 70 pounds this year, has horrible GI problems, and has no teeth.

How do I write this up? I have this:

Imbalanced nutrition (less than body requirements) r/t abdominal pain and difficulty masticating foods as evidenced by patient's pain rating and lack of teeth.

I have to write the r/t as something that an RN can do something about, so I can't say it's r/t the fact that this woman has a series of GI diseases that affect her ability to absorb nutrition.

Any advice?

Thanks!

[learning-2012]

OK- Im brand new at this too.But here is my shot at this.

Imbalanced Nutrition: less than body requirements r/t loss of weight with adequate food intake.

Therapeutic NI for this would be monitoring food intake and recording % eaten..????

Hope this helps. Like I said I am 5 weeks into my very first semester of the ADN program so we are still learning this stuff too.

Good Luck

Just realized that I have nothing saying AMB....?? SEE? I stink at this! LOL!

[sparklie.lady]

Thanks for the input...we can always make it a "risk for" dx, so as to eliminate the AEB...:)