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9 Cards in this Set
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Imbalanced Nutrition: Less than body requirements |
Intake of nutrients insufficient to meet metabolic needs |
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Imbalanced Nutrition < Body Requirements defining characteristics |
Abdominal cramping; abdominal pain; aversion to eating; body weight 20 percent or more under ideal; capillary fragility; diarrhea; excessive loss of hair; hyper active bowel sounds; lack of food; lack of information; lack of interest in food; loos of weight with adequate food intake; misconception; misinformation; pale mucous membranes; perceived inability to digest food; poor muscle tone;sore buccal cavity; weakness of muscles required for swallowing or mastication |
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Imbalanced Nutrition: < Body Requirements Related Fators |
Biological factors; economic factors, inability to absorb nutrients; inability to digest food, inability to ingest food, psychological factors |
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Imbalanced Nutrition: < Body Requirements Client Outcomes |
Client will (specify time frame) Progressively gain weight were desired goal Weigh within normal range for height and age Recognize actors contributing to underweight Identify nutritional requirements Consume adequate nourishment Be free of signs of malnutrition |
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Imbalanced Nutrition < Body Requirements (Nursing Interventions) |
Use a nutritional screen tool to determine possibility of malnutrition on admission into any Healthcare facility Recent weight loss of 10 pounds or 10 percent under healthy weight Not eating for more than 3 days Normal eating for greater than 5 days BMI of less than 20 Recognize that plans with chronic disease related malnutrition (CA, RA, SARCOPENIC OBESITY, Organ Failure) may need calories to maintain nutritional status Monitor for sign of malnutrition including brittle hair that is easily plucked, bruises, dry skin, pale skin and conjunctiva, my phone wasting, market decrease in body fat, smooth red time, cheloisis, flaky paint rash over lower extremity Recognize that severe protein calorie malnutrition can result in septicemia from impairment of the immune system, and organ failure including hartville year, liver failure and respitory dysfunction expescially in critical ill client Monitor lab serum albumin, prealbumin, serum total protien, serum ferritin, transferrin, hemocrit, hemoglobin, electrolytes |
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Imbalanced Nutrition: < Body Requirements (Critical Care) |
Recognize the need to begin and enteral feedings w/in 24 hrs to 48hrs of entrance to cc environment, once the client is freed from hemodynamic compromise, if the client is unable to eat Recognize that it is important to get the ordered feeding into the client, and that frequently checking for gastric residual, checking placement of the tube, can be a limiting factor to adequate nutrition in the tube fed client |
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Imbalanced Nutrition: < Body Requirements (PEDIATRIC) |
Utilize a nutritional screening tool for nurses such as Pediatric York Hill malnutrition score
Watch for symptoms of mount attrition in the children including short stature, , thin arms and legs, poor condition of skin and hair, visible vertebrae & rib cage, wasted buttocks, wasted facial appearance, lethargy, & in extreme cases edema
Wayne and measure the length of child (growth chart)
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Imbalanced Nutrition: < Body Requirements (Geriatric) |
Screen for protien energy malnutrition (screening tool, Mini Nutritional Assessment) Screen for dysphasia, cognitive impairment Lab findings- watch urine color for fluid balance; darker uterine demos dehydration May need to refer to Feeding deficit or Adult failure to thrive |
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Imbalanced Nutrition: < Body Requirements (Home Care) |
Screen for malnutrition using Malnutrition Universal Screen tool Monitor food intake Assess for depression Social factors; lack of transportation, inadequate income, lack of social support Monitor the of TPN, wt, blood glucose, electrolytes, s/sx of fluid overload or deficit, & s/sx of infection @ cath site |
