Risk for: Imbalance Nutrition

Risk for:Imbalance Nutrition

Yadira, Perla & Victoria

case study:

Doña Carmen (78 years old) female who has DM II, HTN, with a history of diabetes. Doña Carmen frequently travels to Mexico and is experiencing high levels of sugar in her blood as well as, high B/P. Doña Carmen does express dietary habits while visiting Mexico are not followed properly. Patient states she experiences episodes of N/V days after returning from Mexico, after visiting for a time span of one week.

assessment:

Patients Past and Current Medical HX

Patient is currently scheduled for a cataract removal surgery on the 13th of March.

• Diabetes Mellitus II- Diagnosed for 10years after son was shot

• Breast cancer- Mammogram detected cancer in stage 2 in 2005, not detectable during patients monthly self exam. Underwent surgery to attempt and remove cancer followed by chemotherapy for 6 months.

• Hypertension- Patient has been suffering of high bloodpressure for 27 years, last two episodes a month ago blood pressure was recorded as 251/127 and 240/117

• No history of alcohol or tobacco use

Vitals

B/P: 160/100P: 62 R: 20 T: 97.7 O2: 98 RA

assessment:

• By assesing the patient, we were able to understand where the patient's present nutritional status is and asseses needs.

• We assesed her chewing and swallowing to be able to identify the possible potential cause of nutritional imbalance.

• She showed no signs of weakness since imbalanced nutrition can decrease the patients strenght and overall safety!!!

• She presented good oral care since it can enhance an individuals appetite.

• Patient reports not being able to control blood pressure and blood sugar levels when traveling. T. Blood pressure reading of 251/127 and BGL of 180

Consctetur siadipiscing elit

Drugs

Metformin 1000mg

• Antidiabetic, oral medication
• Treats Type 2 diabetes

• Adverse Effects: N/V/D, metallic taste heartburn and anorexia

Pt has been presenting with Nausea and Vomiting a few days after change in altitude from recent vacation trips.

ViDEO

nursing dx:

Risk for imbalance nutrition

R/T: Inability to digest food/inability to absorb nutrients. Insufficient dietary intake AEB: Percieved inability to ingest food and insufficient interest in food.

Tor Labor

SMART Goals

• Check/monitor blood glucose levels
• Monitor B/P daily
• Check feet daily
• Weight management
• Healthy eating
• Mental health and well being
• Implement exercise in daily activities.
• Stay updated on vaccinations

PLANNING

Game plan for Ms. Carmen?

Patient should speak with provider regarding possible medication titration during frequent trips

IMPLEMENTATing

• Patient will check sugar levels 3x daily, utilizing a set clock reminder. Patient has glucose meter available
• Monitor B/P: Check B/P once in the AM prior to eating breakfast/medications. Check B/P in the evening.
• Check feet daily: Have family member assist or use a mirror to examine feet for wounds or cuts. Will try to eat healthier during travels
• Implement exercise in daily activities.
• Stay updated on vaccinations

Tempor bore

Patient Education

• Educate the patient on the body’s nutritional needs since this will allow the patient to gain knowledge in the area of how to independently care for herself.

• If the patient is not able to meet the all the body’s requirements during meal times, they can have snacks in order to meet the extra nutritional needs.

• Provide the patient with resources regarding nutrition.

• Take medications as ordered per PCP & make sure patient understands treatment to ensure patient safety.

Evaluation:

• Patient recognized factors that contribute to being under or overweight.
• Patient identifie appropriate nutritional need requirements.
• Patient will continue to consume adequate nutrition.
• Patient verbalized appropriate management of nutrition at home.
• Patient will continue to participate in activities that will continue to reduce cardiac workload.
• Patient will try and maintain B/P within patients normal range.
• Patient will participate in activities that will prevent stress.

References

Imbalanced Nutrition Nursing Diagnosis & Care Plan. (2023, January 6). NurseTogether. https://www.nursetogether.com/imbalanced-nutrition-nursing-diagnosis-care-plan/

CCNS, Betty J. Ackley, MSN, EdS, RN, Gail B. Ladwig, MSN, RN and Mary Beth Flynn Makic, RN, PhD, C. Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care. Available from: VitalSource Bookshelf, (11th Edition). Elsevier Health Sciences (US) Douglas, M. (n.d.). Hypertension Nursing Diagnosis: 6 Care Plans for Any Patient. https://blog.prepscholar.com/hypertension-nursing-diagnosis-care-plan Skidmore-Roth, L. Mosby's 2023 Nursing Drug Reference (36th ed.). Elsevier Health Sciences (US). https://bookshelf.vitalsource.com/books/9780323933315