N
Nausea
NANDA-I
A subjective, unpleasant, wavelike sensation in the back of the throat, epigastrium, or the abdomen that may lead to the urge or need to vomit
Defining Characteristics
Aversion to food; gagging sensation; increased salivation; increased swallowing; report of nausea; sour taste in mouth
Related Factors (r/t)
Biophysical
Biochemical disorders (e.g., uremia, diabetic ketoacidosis, pregnancy); esophageal disease; gastric distention; gastric irritation; increased intracranial pressure; intraabdominal tumors; labyrinthitis; liver capsule stretch; localized tumors (e.g., acoustic neuroma, primary or secondary brain tumors, bone metastases at base of skull); meningitis; Ménière’s disease; motion sickness; pain; pancreatic disease; splenetic capsule stretch; toxins (e.g., tumor-produced peptides, abnormal metabolites due to cancer)
NOC (Nursing Outcomes Classification)
NIC (Nursing Interventions Classification)
Distraction, Medication Administration, Progressive Muscle Relaxation, Simple Guided Imagery, Therapeutic Touch
Nursing Interventions and Rationales
s. Determine cause or risk for N&V (e.g., medication effects, infectious causes, disorders of the gut and peritoneum, central nervous system causes [including anxiety], endocrine and metabolic causes [including pregnancy], postoperative-related status). Because most episodes of N&V are now preventable, it is important for the cause to be determined and appropriate plan and interventions to be developed. Reviewing the client’s medication record and electrolytes is appropriate for early identification of cause of nausea (Makic, 2011). Prophylactic interventions given before chemotherapy have proven to be most successful in preventing N&V. Client expectancy of nausea after chemotherapy is predictive of that treatment-related side effect (Ryan 2010; Shelke et al, 2008).
s. Evaluate and document the client’s history of N&V, with attention to onset, duration, timing, volume of emesis, frequency of pattern, setting, associated factors, aggravating factors, and past medical and social histories. The onset and duration of nausea and vomiting may be distinctly associated with specific events and may be treated differently (Brearley, Clements, & Molassiotis, 2008).
• Document each episode of nausea and/or vomiting separately, as well as effectiveness of interventions. Consider an assessment tool for consistency of evaluation. A systematic approach can provide consistency, accuracy, and measurement needed to direct care. It is important to recognize that nausea is a subjective experience (Brearley, Clements, & Molassiotis, 2008; Kearney et al, 2009; Ryan, 2010; Wood, Chapman, & Eilers, 2011).
• Identify and eliminate contributing causative factors. This may include eliminating unpleasant odors or medications that may be contributing to nausea. These interventions are theory-based; however, there is no research evidence to support outside of expert opinion.
s. Implement appropriate dietary measures such as NPO status as appropriate; small, frequent meals; and low-fat meals. It may be helpful to avoid foods that are spicy, fatty, or highly salty. Reverting to previous practices when ill in the past and consuming “comfort foods” may also be helpful at this time. Expert opinion consensus recommends these interventions, with no research data available (Eaton & Tipton, 2009; Tipton et al, 2007).
s. Recognize and implement interventions and monitor complications associated with N&V. This may include administration of intravenous fluids and electrolytes. Recognition of complications of N&V is critical to prevent and manage complications of dehydration and electrolyte imbalance.
s. Administer appropriate antiemetics, according to emetic cause, by most effective route, considering the side effects of the medication, with attention to and coverage for the timeframes that the nausea is anticipated. Antiemetic medications are effective at different receptor sites and treat different causes of N&V. A combination of agents may be more effective than single agents (Ryan, 2010).
• Consider nonpharmacological interventions such as acupressure, acupuncture, music therapy, distraction, and slow, deliberate movements. Nonpharmacological interventions can augment pharmacological interventions because they predominantly affect the higher cortical centers that trigger N&V. Nonpharmacological interventions are often low cost, relatively easy to use, and have few adverse events. CEB: A review of acupressure studies suggest effectiveness in reducing chemotherapy-induced nausea and vomiting (CINV) when combined with antiemetics (Lee et al, 2008). There is early support for massage and yoga as interventions to reduce nausea in clients receiving chemotherapy, as complements to conventional antiemetics (Billhult, Bergbom, & Stener-Victorin, 2007; Raghavendra et al, 2007).
• Provide oral care after the client vomits. Oral care helps remove the taste and smell of vomitus, thus reducing the stimulus for further vomiting.
Nausea in Pregnancy
• There are no studies of dietary or other lifestyle interventions with any evidence to support traditional advice and interventions. It is often recommended that the woman eat dry crackers or dry toast in bed before arising and then get up slowly. Additional advice includes eatingt small frequent meals, drinking small amounts of fluids often, avoid foods with offensive odors, and avoiding preparing food or shopping when nauseated. These are traditional strategies for alleviating nausea during pregnancy and are considered expert opinion (Festin, 2009).
s. Discuss with the primary care practitioner the possibility of using the P6 acupressure point stimulation to help relieve nausea. EB: A systematic review showed that using P6 acupressure during early pregnancy reduced the proportion of women reporting nausea and vomiting compared to control and is therefore likely to be beneficial (Festin, 2009). It is still unclear whether acupuncture is a helpful intervention (Festin, 2009).
s. Recognize that ginger ingestion may help nausea. Ginger is available in a number of forms including tea, biscuits, and capsules. There are scant randomized controlled clinical trials for use of ginger in pregnancy, with two RCTs showing inconsistent resultsCEB & EB: It is reported that ginger may reduce nausea and vomiting in pregnancy when compared with placebo in early pregnancy; however, effectiveness for ginger in treating hyperemesis gravidarum is still unknown (Ding, Leach, & Bradley, 2012; Festin, 2009; Matthews et al, 2010).
s. Recognize that there are currently no FDA-approved drugs for the treatment of morning sickness, N&V of pregnancy, or hyperemesis gravidarum. There are, however, several pharmacological treatments outlined by the American College of Obstetrics and Gynecology (ACOG). A stepwise, cost-effective strategy may be helpful in approaching nausea with pregnancy. Considerable N&V with associated dehydration may require intravenous antiemetics, hydration, and/or parenteral nutrition (Festin, 2009; Reichmann & Kirkbride, 2008).
Nausea Following Surgery
s. Evaluate for risk factors for postoperative nausea and vomiting (PONV). Strong evidence suggests that client-related risk factors such as female gender, history of PONV, history of motion sickness, nonsmoking behavior, and environmental risk factors such as postoperative opioid use, emetogenic surgery (type and duration), and volatile anesthetics may increase the risk for PONV. Prolonged NPO status, more than 6 hours, has been associated with postop nausea (Makic, 2011). It is important to determine this risk in the preoperative period, to better plan interventions (Ignoffo, 2009).
s. Medicate the client prophylactically for nausea as ordered, throughout the period of risk. EB: Antiemetic medications can reduce the incidence of PONV, and use of combination treatment such as 5-HT3 antagonist plus dexamethasone is more effective than monotherapy (Ignoffo, 2009).
s. Alleviate postoperative pain using ordered analgesic agents (refer to care plan for Acute Pain). Pain is known to be a factor in the development of PONV.
• Consider the use of nonpharmacological techniques, such as P6 acupoint stimulation, as an adjunct for controlling PONV, which has been shown to be effective. EB: Acupuncture and acustimulation have been studied with the most consistent results, similarly effective across methods of stimulation (acupuncture or noninvasive with acupressure or wrist-like electrical stimulation) (Kranke & Eberhart, 2011; Lee & Fan, 2009).
• Use of therapeutic suggestions and ginger may not work as effectively in postdischarge nausea and vomiting (PDNV) (Kranke & Eberhart, 2011).
• Include client education on the management of PONV for all outpatients and discuss key assessment criteria (Ignoffo, 2009).
Nausea Following Chemotherapy
• Perform risk assessment prior to chemotherapy administration. Risk factors include female gender, younger age, history of low alcohol consumption, history of morning sickness during pregnancy, anxiety, previous history of chemotherapy, client expectancy of nausea, and emetic potential of the regimen. It is important to recognize the many risk factors individual clients may have and tailor the antiemetic strategy accordingly. Far too often, the degree of N&V is underestimated by health care providers (Hawkins & Grunberg, 2009).
s. Consult with physician regarding antiemetic strategy, either prophylactic or when N&V occurs. Preventing N&V is important; one failure in antiemetic therapy can result in anticipatory nausea for the remainder of the client’s treatments, and interventions are less likely to be effective (Hawkins & Grunberg, 2009; Ryan, 2010).
• Consider teaching your client to learn how to use acupressure for nausea, applying pressure bilaterally at P6 points using fingers or bands to decrease the amount and severity of nausea. EBN & EB: Finger acupressure can be effective to relieve chemotherapy-induced nausea (Lee et al, 2008). Use of acupressure bands yielded negative results (Lee et al, 2008). Research supports the use of acupressure as an adjunct to pharmacological interventions. Acupressure is a safe, inexpensive, noninvasive technique that has promise for CINV (Lee et al, 2008).
s. Consider the use of ginger root (Zingiber officinale) to relieve nausea. EB: A large study showed that three different daily doses of ginger in capsules with liquefied ginger reduced acute CINV, compared to placebo. In this study clients began the ginger 3 days before chemotherapy and took the ginger in combination with the standard 5-HT3 antagonist antiemetic and dexamethasone (Ryan et al, 2009).
• Consider massage for symptom relief of nausea. EB, EBN, & CEB: Two systematic reviews of massage in cancer clients show suggestion of benefit in the reduction of nausea; however, the variability of areas massaged and the poor quality of studies make it difficult to draw definitive conclusions (Ernst, 2009; Wilkinson, Barnes, & Storey, 2008). An additional small RCT showed significant reduction in nausea, compared to control (Billhult, et al, 2007).
• Consider the use of yoga for CINV. CEB: A small study in breast cancer clients showed a significant decrease in postchemotherapy nausea frequency, nausea intensity, and intensity of anticipatory N&V compared to a control group. This may be a possible stress-reduction technique in conjunction with antiemetics to decrease CINV (Raghavendra et al, 2007).
Geriatric:There are no specific guidelines that address the prophylaxis of CINV in the elderly. Risk still needs to be assessed, although many elderly clients are often treated with less emetic chemotherapy. Chemotherapy, however, can cause increased toxicity due to age-related decreases in organ function, comorbidities, and drug-drug interactions secondary to polypharmacy. Additionally, adherence may be an issue, due to cognitive decline, impaired senses, and economic issues. Increased caution is warranted with this population due to increased safety concerns (Jakobsen & Herrstedt, 2009).
Pediatric:• Interventions for CINV should be implemented prior to and after chemotherapy. Despite the extensive use of antiemetics, up to 58% of school-age and adolescent-age children receiving highly emetogenic chemotherapy is reported. Delayed CINV occurs most frequently with greater severity and distress (Rodgers et al, 2011).
• Relatively few studies exist examining the antiemetic medications used for CINV in children. It appears that 5-HT3 antagonists combined with dexamethasone are better than older agents (Phillips et al, 2011).
Home Care:• Previously mentioned interventions may be adapted for home care use.
s. In hospice care clients, assess for causes of nausea, such as constipation, bowel obstruction, adverse effects of medications, and onset of increased intracranial pressure. Refer the client to a primary care practitioner if needed. There can be multiple causes of nausea in clients with advanced cancer (Pantilat & Issac, 2008). EBN: Clients receiving oral chemotherapy at home benefited from a home nursing care program, which significantly helped to decrease symptoms, including nausea, when compared to standard care (Molassiotis et al, 2009).
• Assist the client and family with identifying and avoiding irritants in the home that exacerbate nausea (e.g., strong odors from food, plants, perfume, and room deodorizers). All medications except antiemetics should be given after meals to minimize the risk of nausea.
Client/Family Teaching and Discharge Planning:
• Teach the client techniques to use before and after chemotherapy, including antiemetics/medication management schedules and relaxation techniques, guided imagery, hypnosis, and music therapy. Client safety is a priority with polypharmacy and significant side effects that the client may experience at home (Eaton & Tipton, 2009; Tipton et al, 2007).
References
Billhult, A., Bergbom, I., Stener-Victorin, E. Massage relieves nausea in women with breast cancer who are undergoing chemotherapy. J Altern Complement Med. 2007;13(1):53–57.
Brearley, S.G., Clements, C.V., Molassiotis, A. A review of patient self-report tools for chemotherapy-induced nausea and vomiting. Support Care Cancer. 2008;16(11):1213–1229.
Ding, M., Leach, M., Bradley, H. The effectiveness and safety of ginger for pregnancy-induced nausea and vomiting: a systematic review. Women Birth. August 27, 2012. [Epub ahead of print].
Eaton, L.H., Tipton, J.M. Putting evidence into practice: improving oncology patient outcomes. Pittsburgh, PA: Oncology Nursing Society; 2009.
Ernst, E. Massage therapy for cancer palliation and supportive care: A systematic review of randomised clinical trials. Support Care Cancer. 2009;17:333–337.
Festin M: Nausea and vomiting in early pregnancy, Clin Evid (online), 1-20. Retrieved Sept 19, 2012, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907767/.
Grunberg, S.M., et al. Incidence of chemotherapy-induced nausea and emesis after modern antiemetics. Cancer. 2004;100(10):2261–2268.
Hawkins, R., Grunberg, S. Chemotherapy-induced nausea and vomiting: challenges and opportunities for improved patient outcomes. Clin J Oncol Nurs. 2009;13(1):54–64.
Kearney, N., et al. Evaluation of a mobile phone-based, advanced symptom management system (ASyMS) in the management of chemotherapy-related toxicity. Support Care Cancer. 2009;17:437–444.
Kranke, P., Eberhart, L. Possibilities and limitations in the pharmacological management of postoperative nausea and vomiting. Eur J Anaesthesiol. 2011;28(11):758–765.
Ignoffo, R.J. Current research on PONV/PDNV: practical implications for today’s pharmacist. Am J Health Syst Pharmacist. 2009;66(1 Suppl 1):S19–S24.
Jakobsen, J.N., Herrstedt, J. Prevention of chemotherapy-induced nausea and vomiting in elderly cancer patients. Crit Rev Oncol Hematol. 2009;71(3):214–221.
Lee, J., Fan, L.T. Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting. Cochrane Database Syst Rev. 2009;15(2):CD003281.
Lee, J., et al. Review of acupressure studies for chemotherapy-induced nausea and vomiting control. J Pain Symptom Manage. 2008;36(5):529–544.
Makic, M.B. Management of nausea, vomiting and diarrhea during critical illness. Adv Crit Care Nurs. 2011;22(3):265–274.
Matthews, A., et al, Interventions for nausea and vomiting in early pregnancy. Cochrane Database Syst Rev 2010;(9):CD007575.
Molassiotis, A., et al. Effectiveness of a home care nursing program in the symptom management of patients with colorectal and breast cancer receiving oral chemotherapy: a randomized, controlled trial. J Clin Oncol. 2009;27(36):6191–6198.
Pantilat, S.Z., Issac, M. End-of-life care for the hospitalized patient. Med Clin North Am. 2008;92:349–370.
Phillips, R.S., et al, Antiemetic medication for prevention and treatment of chemotherapy induced nausea and vomiting in childhood. Cochrane Database Syst Rev 2010;(9):CD007786.
Raghavendra, R.M., et al. Effects of an integrated yoga programme on chemotherapy-induced nausea and emesis in breast cancer patients. Eur J Cancer Care. 2007;16(6):462–474.
Reichmann, J.P., Kirkbride, M.S. Nausea and vomiting of pregnancy: cost-effective pharmacologic treatments. Manag Care. 2008;17(12):41–45.
Rodgers, C., et al. Nausea and vomiting perspectives among children receiving moderate to highly emetogenic chemotherapy treatment. Cancer Nurs. 2012;35(3):203–210.
Ryan, J.L. Treatment of chemotherapy-induced nausea in cancer patients. Eur Oncol. 2010;6(2):14–16.
Ryan, J.L., et al. Ginger for chemotherapy-related nausea in cancer patients: a URCC CCOP randomized, double-blind, placebo-controlled clinical trial of 644 patients. J Clin Oncol. 27, 2009. [(15S suppl abstr):9511].
Sheehan, P. Hyperemesis gravidarum. Aust Fam Phys. 2007;36(9):698–701.
Shelke, A.R., et al. Effect of a nausea expectancy manipulation on chemotherapy-induced nausea: a University of Rochester Cancer Center Community Clinical Oncology Program study. J Pain Symptom Manage. 2008;35(4):381–387.
Steele, A., Carlson, K.K. Nausea and vomiting: applying research to bedside practice. AACN Adv Crit Care. 2007;18(1):61–75.
Tipton, J.M., et al. Putting evidence into practice: evidence-based interventions to prevent, manage, and treat chemotherapy-induced nausea and vomiting. Clin J Oncol Nurs. 2007;11(1):69–78.
Wilkinson, S., Barnes, K., Storey, L. Massage for symptom relief in patients with cancer: systematic review. J Adv Nurs. 2008;63(5):430–439.
Wood, J.M., Chapman, K., Eilers, J. Tools for assessing nausea, vomiting, and retching. Cancer Nurs. 2011;34(1):E14–E24.
Noncompliance
NANDA-I
Behavior of person and/or caregiver that fails to coincide with a health-promoting or therapeutic plan agreed on by the person (and/or family and/or community) and health care professional. In the presence of an agreed-on, health-promoting, or therapeutic plan, person’s or caregiver’s behavior is fully or partially nonadherent and may lead to clinically ineffective or partially ineffective outcomes
Defining Characteristics
Behavior indicative of failure to adhere; evidence of development of complications; evidence of exacerbation of symptoms; failure to keep appointments; failure to progress; objective tests (e.g., physiological measures, detection of physiological markers)
Related Factors (r/t)
Health System
Access to care, communication skills of the provider, convenience of care, credibility of provider, difficulty in client-provider relationship, individual health coverage, provider continuity, provider regular follow-up, provider reimbursement, satisfaction with care, teaching skills of the provider
Individual Factors
Cultural influences, developmental abilities, health beliefs; deficient knowledge relevant to the regimen behavior; individual’s value system, motivational forces, personal abilities, significant others, skill relevant to the regimen behavior, spiritual values
Network
Involvement of members in health plan; perceived beliefs of significant others; social value regarding plan
Note: The nursing diagnosis Noncompliance is judgmental and places blame on the client. The authors recommend use of the diagnosis Ineffective Self-Health Management in place of the diagnosis Noncompliance. The diagnosis Ineffective Self-Health Management has interventions that are developed by both the health care providers and the client. It is a more respectful and efficacious nursing diagnosis than Noncompliance.
Readiness for enhanced Nutrition
NANDA-I
Defining Characteristics
Attitude toward drinking is congruent with health goals; attitude toward eating is congruent with health goals; consumes adequate fluid; consumes adequate food; eats regularly; expresses knowledge of healthy fluid choices; expresses knowledge of healthy food choices; expresses willingness to enhance nutrition; follows an appropriate standard for intake (e.g., the American Diabetic Association guidelines); safe preparation for fluids; safe preparation for food; safe storage for food and fluids
NOC (Nursing Outcomes Classification)
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Ask the client to keep a 1- to 3-day food diary where everything eaten or drunk is recorded. Analyze the quality, quantity, and pattern of food intake. Use of a food diary is helpful for both the client and the nurse, to examine usual foods eaten and patterns of eating (Shay et al, 2009).
• Advise the client to measure food periodically. Help the client learn usual portion sizes. Measuring food alerts the client to normal portion sizes. Estimating amounts can be extremely inaccurate. EB: A study demonstrated that obese people had significantly larger portion sizes, plus ate later in the day (Berg et al, 2009).
• Help the client determine his or her body mass index (BMI). Use a chart or a website such as http://www.cdc.gov/healthyweight/assessing/bmi/index.html (CDC, 2012). A normal BMI is 20 to 25; 26 to 29 is overweight; and a BMI of 30 or greater is obese. Clients with increased muscle mass may be labeled overweight, when in reality they are very physically fit. Also, clients who have lost large amounts of muscle mass may be in the healthy range, when in reality they may be malnourished (Camden, 2009). EB: An analysis of 57 studies demonstrated that mortality was lowest for people with a BMI of 22.5 to 25. Each 5-unit increase above a BMI of 25 resulted in an increased mortality rate by 30% (Whitlock et al, 2009).
• Recommend the client follow the U.S. Dietary Guidelines to determine foods to eat, which can be found at http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/ExecSumm.pdf. Dietary guidelines are written by national experts and are based on research in nutrition (USDA, 2010).
• Recommend the client use Super Tracker (http://www.choosemyplate.gov/food-groups) to determine the number of calories to eat and gain more information on how to eat in a healthy fashion. To lose weight, the client must eat fewer calories (USDA, 2010).
• Recommend the client eat a healthy breakfast every morning. CEB: A study found that that people who skip breakfast are more likely to overeat in the evening (Masheb & Grillo, 2006). Another study demonstrated that people who skipped breakfast were 450 times more likely to be obese (Ma et al, 2003).
• Recommend the client avoid eating in fast food restaurants. CEB: A 15-year study demonstrated that people who frequently eat fast foods gain an average of 10 lb more than those who eat fast food less often and were two times more likely to develop insulin resistance, which can lead to diabetes (Peirera et al, 2005).
• Demonstrate the use of food labels to make healthful choices. Alert the client/family to focus on serving size, total fat, and simple carbohydrate. The standardized food label in bold type simplifies the search for information. Fats and sugars contribute the least to a healthful diet and the most to excessive calorie intake.
Carbohydrates/Sugars
• Encourage the client to decrease intake of sugars, including intake of soft drinks, desserts, and candy. Limit sugar intake to 6.5 teaspoons of added sugars for women and 9.5 teaspoons of added sugar for men daily.
• Share with client the names of sugars include glucose, dextrose, corn syrup, maple syrup, brown sugar, molasses, evaporated cane juice, sucrose, honey, orange juice concentrate, grape juice concentrate, apple juice concentrate, brown rice syrup, high-fructose corn syrup, agave, and fructose (Nutrition Action, 2012). Sugar predisposes to type 2 diabetes, heart disease, high blood pressure, high triglycerides, gout, and weight gain. EB: Studies comparing sugary and diet drinks demonstrated that sugary drinks increase visceral fat which expands waistlines and drives insulin resistance, predisposing to type 2 diabetes and heart disease (Hu & Malik, 2010; Odegaard et al, 2012).
• Limit intake of fruit juice to 1 cup per day. EB: Studies have shown that people who drank more fruit juice had a greater risk of type 2 diabetes or weight gain (Odegaard et al, 2010; Pan et al, 2012).
• Recommend the client eat whole grains whenever possible, and explain how to find whole grains using the food label. EB: A review of studies found strong evidence that eating whole grains is associated with a decreased BMI and reduced the risk of being overweight (Williams, Grafenauer, & O’Shea, 2008). Intake of whole grains has been shown to decrease the incidence of heart failure (Nettleton et al, 2008) and, when eaten with other healthier foods, resulted in lower incidence of diabetes in a multiethnic study (Nettleton et al, 2008).
• Evaluate the client’s usual intake of fiber. Recommended intake is 25 g per day for women and 38 g per day for men. Increase intake of whole grains, beans, fruits, and vegetables to obtain needed fiber. Wheat bran is an excellent source of fiber, but cannot be tolerated by all people; beans are the second-best source of fiber (Nutrition Action, 2011). In general, high-fiber foods take longer to eat, increase satiety, and contain fewer calories than most other foods (Slavin, 2008).
• Recommend the client eat five to nine fruits and vegetables per day, with a minimum of two servings of fruit and three servings of vegetables. Encourage client to eat a rainbow of fruits and vegetables because bright colors are associated with increased nutrients. Both fruits and vegetables are excellent sources of vitamins and also phytochemicals that help protect from disease, strokes, some kinds of cancer, and possibly macular degeneration (Liebman & Hurley, 2009). EB: A study done on older men found that if they ingested increased foods high in vitamin C, it resulted in decreased thickening of the carotid arteries (Ellingsen et al, 2009).
Fats
• Recommend the client limit intake of saturated fats and avoid trans fatty acids completely; instead increase intake of vegetable oils such as polyunsaturated and monounsaturated oils. EB: A Cochrane study showed that decreasing intake of saturated fats, replacing them with unsaturated oils, was effective in decreasing cardiovascular risk (Hooper, 2001). Intake of both saturated fat and trans fatty acids raises the low-density lipoprotein (LDL) level, which predisposes to atherosclerosis with cardiovascular disease (Zelman, 2011).
• Recommend client use low-fat choices when selecting and cooking meat, and also when selecting dairy products.
• Recommend that the client eat cold-water fish such as salmon, tuna, or mackerel at least two times per week to ensure adequate intake of omega-3 fatty acids. If unwilling to eat fish, suggest sources such as flaxseed, soy, or walnuts. Note: Fish oil capsules should be taken cautiously; some brands can be contaminated with mercury or pesticides. Intake of excessive omega-3 fatty acids can result in bleeding. Ingestion of omega-3 fats results in lower triglycerides and total cholesterol and also decreases the risk of heart disease and stroke (Neville, 2009). CEB: The intake of omega-3 fatty acids by eating fish or fish oil capsules results in decreased incidence of sudden cardiac death (von Schacky, 2007).
Protein
• Recommend the client decrease intake of red meat and processed meats, instead eat more poultry, fish, soy, and dairy sources of protein. EB: Red and processed meat intakes were associated with increases in mortality for cancer, and cardiovascular disease (Sinha et al, 2009).
• Recommend the client eat meatless meals at intervals and try alternative sources of protein, including nuts, especially almonds (one handful), and nut butters. EB: Consumption of nuts and peanut butter was shown to decrease the incidence of cardiovascular disease in women with type 2 diabetes (Li et al, 2009). A study found that diabetic people who ate walnuts regularly had improved endothelial function, and healthier blood vessels, and also lower low-density lipoproteins and total cholesterol (Ma et al, 2010).
• Recommend the client eat beans and soy as an alternative to animal proteins at intervals. Introduce the client to soy products such as flavored soy milk and tofu. Note: Women with diagnosed estrogen-dependent cancer of the breast should generally avoid eating soy foods. EB: Research has shown that intake of soy foods as a child may cut the incidence of breast cancer by half, and may protect women from breast cancer in a Chinese study, but further research is needed (Welland, 2007).
Fluid and Electrolytes
• Recommend the client choose and prepare foods with less salt, aiming for a maximum of 2,300 mg per day (Harvard Health Letter, 2012). The CDC (2009) recommends that all salt-sensitive Americans, including everyone 40 years or older, should decrease daily sodium intake. EB: A study found that decreased sodium intake helped lower blood pressure, as well as increase flexibility in blood vessels, improving the health of the blood vessels (CDC, 2009).
• If the client drinks alcohol, encourage him or her to drink in moderation—no more than one drink per day for women and two drinks per day for men. EB: A study found an increased incidence of cancer of the upper gastrointestinal tract, liver cancer, and also renal cancer (Thygesen et al, 2009).
• Recommend client increase intake of water, to at least 2000 mL or 2 quarts per day. A guideline is 1 to 1.5 mL of fluid for each calorie needed, so an average intake would be between 2000 and 3000 mL/day, or at least 8 cups of fluid. EB: The adequate intake recommendation is 3 L for the 19- to 30-year-old male and 2.2 L for the 19- to 30-year-old female. Water balance studies suggest that adult men require 2.5 L per day (Institute of Medicine, 2004).
Supplements
• Recommend that clients utilize dietary supplements such as vitamins and minerals only after consulting with their primary care practitioner (Mayo Clinic Health Letter, 2012). EB: A large study performed on women found that those who took more supplements had an increased risk of death, especially with intake of multivitamins, vitamin B6, folic acid, iron, magnesium, zinc, and copper. Calcium seemed to decrease the risk of death (Mursu et al, 2011). CEB: A review of 14 randomized trials demonstrated that intake of antioxidant supplementation did not prevent gastrointestinal (GI) cancers, and intake seemed to increase mortality (Bjelakovic et al, 2004).
• Recommend that families eat together for at least one meal per day. Mealtime together has been shown to improve children’s eating habits: children eat more fruits and vegetables when the family eats together.
• Recommend involving the family in planning meals and food preparation. Children can learn about nutrition as they help plan and make meals. Children are more likely to eat foods that they help select or prepare.
• Suggest that parents work at being good role models of healthy eating. Setting a good example is key for children; children learn the value of healthy eating early, and it can continue for a lifetime.
• Recommend that the family try new foods, either a new food or recipe every week. More variety can increase the intake of fruits and vegetables.
• Suggest the parents keep healthy snacks on hand. Store the snacks in a purse, the car, a desk drawer. Suggestions include crackers and peanut butter, small boxes of cereal, fresh fruit, and vegetables (Academy of Nutrition and Dietetics, 2012).
• Plan ahead before eating out. Visit restaurant websites to see the nutritional value of foods on the menu; also call ahead to see what is offered for healthy foods. Most mothers want their families to eat healthier, but with busy schedules, this can be difficult.
• Utilize a nutritional screening tool designed for the elderly such as the Mini Nutrition Assessment (MNA), the Malnutrition Universal Screening Tool (MUST), or the Nutrition Risk Screening (NRS). The MNA is helpful for the elderly person living in the community or in an extended care facility; the NRS is more helpful for clients in the acute care setting (Sieber, 2006).
• Assess changes in lifestyle and eating patterns. Geriatric clients need to decrease portion size as they get older because they are not burning as many calories. Energy needs decrease an estimated 5% per decade after age 40 years, but often, eating patterns remain unchanged from youth (Lutz & Przytulski, 2011).
• Assess fluid intake. Recommend routine drinks of water regardless of thirst. Monitor elderly clients for deficient fluid volume carefully, noting new onset of weakness, dizziness, and postural hypotension. Older adults have a higher osmotic point for thirst sensation and a diminished sensitivity to thirst, relative to younger adults (Wotton, Crannitch, & Munt, 2008).
• Observe for socioeconomic factors that influence food choices (e.g., funds, cooking facilities). Even those on restricted budgets and with limited facilities can be assisted to choose healthy food sources for a balanced diet.
Multicultural:• Assess for the influence of cultural beliefs, norms, and values on the client’s nutritional knowledge. What the client considers normal dietary practices may be based on cultural perceptions (Giger & Davidhizar, 2008).
• Discuss with the client those aspects of his or her diet that will remain unchanged. Aspects of the client’s life that are meaningful and valuable to them should be understood and preserved without change if possible.
References
Academy of Nutrition and Dietetics, It’s about eating right: nutrition for growing bodies 2012 http://www.eatright.org/Public/content.aspx?id=6751 [Retrieved June 13, 2012, from].
Berg, C., et al. Eating patterns and portion size associated with obesity in a Swedish population. Appetite. 2009;52(1):21–26.
Bjelakovic, G., et al. Antioxidant supplements for prevention of gastrointestinal cancers: a systematic review and meta-analysis. Lancet. 2004;364(9441):1219–1228.
Camden, S. Obesity: an emerging concern for patients and nurses. Online J Issues Nurs. 2009;14(1):5–17.
Centers for Disease Control and Prevention (CDC). Application of lower sodium intake recommendations to adults-United States, 1999-2006. MMWR Morb Mortal Wkly Rep. 2009;58(11):281–283.
Centers for Disease Control and Prevention (CDC), Healthy weight, it is not a diet, it is a lifestyle. BMI calculator 2011 http://www.cdc.gov/healthyweight/assessing/bmi/index.html [Retrieved June 10, 2012, from].
Centers for Disease Control and Prevention (CDC), Healthy weight, It’s not a diet, it’s a lifestyle. BMI calculator 2012 http://www.cdc.gov/healthyweight/assessing/bmi/index.html [Retrieved June 13, 2012, from].
Ellingsen, I., et al. Vitamin C consumption is associated with less progression in carotid intima media thickness in elderly men: a 3-year intervention study. Nutr Metab Cardiovasc Dis. 2009;19(1):8–14.
Giger, J., Davidhizar, R. Transcultural nursing: assessment and intervention, ed 5. St Louis: Mosby; 2008.
Harvard Health Letter: Keep a lookout for sodium, 37(4):1, 2012.
Hooper, L., et al. Reduced or modified dietary fat for preventing cardiovascular disease. Cochrane Database Syst Rev. 2012;16(5):CD002137.
Hu, F.B., Malik, V.S. Sugar-sweetened beverages and risk of obesity and type 2 diabetes: epidemiologic evidence. Physiol Behav. 2010;100(1):47–54.
Institute of Medicine. Applications of dietary reference intakes for electrolytes and water. Washington, DC: National Academies Press; 2004.
Li, T.Y., et al. Regular consumption of nuts is associated with a lower risk of cardiovascular disease in women with type 2 diabetes. J Nutr. 2009;139(7):1333–1338.
Liebman, B., Hurley, J. Rating rutabagas: not all vegetables are created equal. Nutr Action Healthletter. 2009. [Jan:13-15].
Lutz, C.A., Przytulski, K.R. Nutrition and diet therapy, ed 5. Philadelphia: FA Davis; 2011.
Ma, Y., et al. Association between eating patterns and obesity in a free-living U.S. adult population. Am J Epidiomol. 2003;158(1):85–92.
Ma, Y., et al. Effects of walnut consumption on endothelial function in type 2 diabetic subjects: a randomized controlled crossover trial. Diabetes Care. 2010;33(2):227–232.
Masheb, R.M., Grillo, C.M. Eating patterns and breakfast consumption in obese patients with binge eating disorder. Behav Res Ther. 2006;44(11):1545–1553.
Mayo Clinic Health Letter: Risks of vitamin supplements, March 4, 2012.
Mursu, J., et al. Dietary supplements and mortality rate in older women: the Iowa Women’s Health Study. Arch Intern Med. 2011;171(18):1625–1633.
Nettleton, J.A., et al. Dietary patterns and risk of incident type 2 diabetes in the Multi-Ethnic Study of Atherosclerosis (MESA). Diabetes Care. 2008;31(9):1777–1782.
Neville, K. Focus on good fats: balancing omega-3s with omega-6s. Environ Nutr. 2009;32(3):1–4.
Nutrition Action HealthLetter: Eat smart: which foods are good for what, December, 2011.
Odegaard, A.O., et al. Soft drink and juice consumption and risk of physician-diagnosed incident type 2 diabetes: the Singapore Chinese Health Study. Am J Epidemiol. 2010;171(6):701–708.
Odegaard, A.O., et al. Sugar-sweetened and diet beverages in relation to visceral adipose tissue. Obesity (Silver Spring). 2012;20(3):689–691.
Pan, A., et al. Plain-water intake and risk of type 2 diabetes in young and middle-aged women. Am J Clin Nutr. 2012;95(6):1454–1460.
Pereira, M.A., et al. Fast-food habits, weight gain, and insulin resistance (the CARDIA study): 15-year prospective analysis. Lancet. 2005;365(9453):36.
Shay, L.E., et al. Adult weight management: translating research and guidelines into practice. J Am Acad Nurse Pract. 2009;21(4):197–206.
Sieber, C.C. Nutritional screening tools-how does the MNA compare? Proceedings of the session held in Chicago May 2-3, 2006 (15 Years of Mini Nutritional Assessment). J Nutr Health Aging. 2006;10(6):488–492.
Sinha, R., et al. Meat intake and mortality: a prospective study of over half a million people. Arch Intern Med. 2009;169(6):562–571.
Slavin, J.L. Position of the American Dietetic Association: health implications of dietary fiber. J Am Diet Assoc. 2008;108(10):1716–1731.
Thygesen, L.C., et al. Cancer incidence among patients with alcohol use disorders—long-term follow-up. Alcohol Alcohol. 2009;44(4):387–391.
United States Department of Agriculture (USDA), USDA U.S. dietary guidelines: executive summary 2010 http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/ExecSumm.pdf [Retrieved June 10, 2012, from].
von Schacky, C. Omega-3 fatty acids and cardiovascular disease. Curr Opin Clin Nutr Metab Care. 2007;10(2):129–135.
Welland, D. Red-flagging food labels: 8 tips to sift fact from fiction. Environ Nutr. 2007;30(3):2.
Whitlock, G., et al. Body-mass index and cause-specific mortality in 900,000 adults: collaborative analyses of 57 prospective studies. Lancet. 2009;373(9669):1083–1096.
Williams, P.G., Grafenauer, S.J., O’Shea, J.E. Cereal grains, legumes, and weight management: a comprehensive review of the scientific evidence. Nutr Rev. 2008;66(4):171–182.
Wotton, K., Crannitch, K., Munt, R. Prevalence, risk factors and strategies to prevent dehydration in older adults. Contemp Nurse. 2008;31(1):44–56.
Zelman, K. The great fat debate: a closer look at the controversy—questioning the validity of age-old dietary guidance. J Am Dietetic Assoc. 2011;111(5):655–658.
Imbalanced Nutrition: less than body requirements
NANDA-I
Defining Characteristics
Abdominal cramping; abdominal pain; aversion to eating; body weight 20% or more under ideal; capillary fragility; diarrhea; excessive loss of hair; hyperactive bowel sounds; lack of food; lack of information; lack of interest in food; loss of weight with adequate food intake; misconceptions; misinformation; pale mucous membranes; perceived inability to ingest food; poor muscle tone; reported altered taste sensation; reported food intake less than RDA (recommended daily allowance); satiety immediately after ingesting food; sore buccal cavity; steatorrhea; weakness of muscles required for swallowing or mastication
NOC (Nursing Outcomes Classification)
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
s. Use a nutritional screening tool to determine possibility of malnutrition on admission into any health care facility. Watch for recent weight loss of over 10 lb, 10% under healthy weight, not eating for more than 3 days, ½ normal eating for greater than 5 days, and body mass index (BMI) of less than 20, or other reasons why the client may be malnourished, and refer to a dietitian for a complete nutritional assessment (Lutz & Przytulski, 2010). EB & CEB: Research has shown that from 23% to 50% of all clients are malnourished on admission, and the presence of malnutrition increases the length of hospital stay (Gout, Barker, & Crowe, 2009; Somanchi, Tao, & Mullin, 2011).
• Recognize that clients with acute disease or injury-related malnutrition, wounds, recent surgery, trauma, and a fever are using more calories and need increased calories to maintain their nutritional status (Lutz & Przytulski, 2010; White, Guenter, & Gordon, 2012).
• Recognize that clients with chronic disease-related malnutrition (cancer, rheumatoid arthritis, sarcopenic obesity, organ failure) may need calories to maintain nutritional status (White et al, 2012).
• Monitor for signs of malnutrition, including brittle hair that is easily plucked, bruises, dry skin, pale skin and conjunctiva, muscle wasting, marked decrease in body fat, smooth red tongue, cheilosis, and a “flaky paint” rash over lower extremities (Klein, 2011).
• Recognize that severe protein-calorie malnutrition can result in septicemia from impairment of the immune system, and organ failure including heart failure, liver failure, and respiratory dysfunction, especially in the critically ill client. Untreated malnutrition can result in multiple organ failure and death (Klein, 2011).
s. Note laboratory test results as available: serum albumin, prealbumin, serum total protein, serum ferritin, transferrin, hemoglobin, hematocrit, and electrolytes. A serum albumin level of less than 3.5 is considered an indicator of risk of poor nutritional status (Dwyer, 2011).
• Weigh the client daily in acute care, weekly to monthly in extended care at the same time (usually before breakfast), with same amount of clothing.
s. Monitor food intake; record percentages of served food that is eaten (25%, 50%, 75%, 100%). Keep a 3-day food diary to determine actual intake; consult with dietitian for actual calorie count if needed. Use of a food diary is helpful for both the client and the nurse, to examine usual foods eaten, patterns of eating, and presence of deficiencies in the diet (Shay et al, 2009).
• Observe the client’s relationship to food. Attempt to separate physical from psychological causes for eating difficulty. EBN: Not eating adequate amounts of food may be a symptom of depression (Johansson et al, 2009).
• Evaluate the intake of the client using the United States Department of Agriculture’s My Tracker online software, available at https://www.choosemyplate.gov/SuperTracker/default.aspx (U.S. Department of Agriculture, 2010).
• If the client is a vegetarian, evaluate vitamin B12 and iron intake. Strict vegetarians (vegans) may be at particular risk for vitamin B12 and iron deficiencies. Special care should be taken when implementing vegetarian diets for pregnant women, infants, children, and the elderly. A dietitian can furnish a balanced vegetarian diet (with adequate substitutes for omitted foods) for inpatients and can provide instruction for outpatients (O’Regan, 2009).
• Observe the client’s ability to eat (time involved, motor skills, visual acuity, and ability to swallow various textures). If the client needs to be fed, allocate at least 35 minutes to feeding. Clients in institutions are susceptible to protein-calorie malnutrition (PCM) when they are unable to feed themselves. CEB & EB: Research demonstrates it takes at least 35 minutes to feed the client who is willing to eat (Simmons, 2008Simmons, Osterweil, & Schnelle, 2001; Simmons & Schnelle, 2004).
note: If the client is unable to feed self, refer to Nursing Interventions for Feeding Self-Care deficit. If the client has difficulty swallowing, refer to Nursing Interventions for Impaired Swallowing. If the client is receiving tube feedings, refer to the Nursing Interventions for Risk for Aspiration.
• If the client has a minimally functioning gastrointestinal tract and is on clear fluids, consult with dietitian regarding use of a clear liquid product that contains increased amounts of protein and calories such as Ensure Alive, Resource Breeze Fruit Beverage, or citrotein (Lutz & Przytulski, 2010).
• For the client with anorexia, who will not eat foods, consider offering 30 mL of a nutritional supplement in a medication cup every hour, often during medication rounds. EB: A Cochrane review demonstrated that there was a small but consistent weight gain along with a positive effect on mortality in elderly clients who received a nutritional supplement (Milne et al, 2009).
• For the client who is malnourished and can eat, offer small quantities of energy-dense and protein-enriched food, served in an appetizing fashion, at frequent intervals. CEB: Fortified foods, such as those with increased protein, were acceptable to clients if they tasted the same as regular foods (Dunne & Dahl, 2007).
• For the client who is able to eat, but has a decreased appetite, try the following activities:
Offer foods that are familiar to the client and do not offend his/her beliefs. All people like to eat foods to which they are accustomed, especially when ill (O’Regan, 2009).
Avoid interruptions during mealtimes; meals should be eaten in a calm and peaceful environment. Interruptions have a negative effect on client’s nutrition. Some hospitals have started a “protected mealtime” effort to ensure that clients are not disturbed during mealtime (Hallpike, 2008; O’Regan, 2009).
Make food available as desired between early evening and breakfast. There can be a 14-hour time span between the evening meal and breakfast; having foods available in the evening and before bedtime, as well as any time desired, can increase nutritional intake (O’Regan, 2009).
Use colored trays to identify clients who need help eating or who are at nutritional risk. This system is a visible reminder of the client’s nutritional needs (O’Regan, 2009).
• If the client lacks endurance, schedule rest periods before meals, and open packages and cut up food for the client. Nursing assistance will conserve the client’s energy for eating.
• Watch carefully for signs of infection and maintain every action possible to protect the client from infection. Protein-energy malnutrition is associated with a significant decrease in immunity; there is a decrease in leukocytes, lymphocytes, and the overall function of the immune system (Klein, 2011).
• Provide companionship at mealtime to encourage nutritional intake. Mealtime usually is a time for social interaction; often clients will eat more food if other people are present at mealtimes.
• Monitor state of oral cavity (gums, tongue, mucosa, teeth). Provide good oral hygiene before each meal. Good oral hygiene enhances appetite; the condition of the oral mucosa is critical to the ability to eat. The oral mucosa must be moist, with adequate saliva production to facilitate and aid in the digestion of food.
s. Administer antiemetics and pain medications as ordered and needed before meals. The presence of nausea or pain decreases the appetite.
• If client is nauseated, remove cover of food tray before bringing it into the client’s room. The sudden, concentrated food odors that come when the cover is removed in front of the client can trigger nausea.
• Work with the client to develop a plan for increased activity. Immobility leads to negative nitrogen balance that fosters anorexia.
• If the client is anemic, offer foods rich in iron and vitamins B12, C, and folic acid. Iron in meat, fish, and poultry is absorbed more readily than iron in plants. Vitamin C increases the solubility of iron. Vitamin B12 and folic acid are necessary for erythropoiesis (Lutz & Przytulski, 2010).
• For the agitated, pacing client, offer finger foods (sandwiches, fresh fruit) and fluids. If a client cannot be still, food can be consumed while pacing.
s. If client has been malnourished for a significant length of time, consult with the dietitian and refeed carefully after correcting electrolyte balance. Watch for heart and respiratory failure. Refeeding syndrome, a potentially fatal condition, occurs in some malnourished clients when nutrients are given in excess of the client’s ability to metabolize them. Clients at risk of refeeding syndrome must be monitored carefully for electrolyte imbalances, congestive heart failure, and respiratory failure (Adkins, 2009; Klein, 2011).
Critical Care
• Recognize the need to begin enteral feedings within 24 to 48 hours of entrance into the critical care environment, once the client is free of hemodynamic compromise, if the client is unable to eat. Providing nutrition early helps maintain muscle and immune system function, lower infection rate, decrease gut permeability, decrease incidence of multiple organ failure, aid wound healing, and reduce hospital length of stay (McClave et al, 2009; Racco, 2009; Somanchi, Tao, & Mullin, 2011).
• Recognize that it is important to get the ordered feedings 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. EBN: A study found that critical care clients received only 50% of the ordered enteral formula because of frequent interruptions of tube feedings due to problems with small-bore feeding tubes, checking placement, and other care of the tube-fed client (O’Meara et al, 2008). Refer to care plan Risk for Aspiration.
• If the client is pregnant, ensure that she is receiving adequate amounts of folic acid by eating a balanced diet and taking prenatal vitamins as ordered. All women of childbearing potential are urged to consume 400 mcg of synthetic folic acid from fortified foods or supplements in addition to food folate from a varied diet to prevent birth defects (Lutz & Przytulski, 2010).
s. Utilize a nutritional screening tool designed for nurses such as the Paediatric Yorkhill Malnutrition Score (PYMS) tool, and if the child has a score of 2 or more, make a referral to a dietitian. EB: A study found that use of the PYMS was helpful in identifying children with malnutrition and was able to identify children with malnutrition who would not have been referred for treatment (Gerasimidis et al, 2011).
• Watch for symptoms of malnutrition in the child including short stature, thin arms and legs, poor condition of skin and hair, visible vertebrae and rib cage, wasted buttocks, wasted facial appearance, lethargy, and in extreme cases, edema.
• Weigh and measure the length (height) of the child and use a growth chart to help determine growth pattern, which reflects nutrition. Age-related growth charts are available from this website: http://www.keepkidshealthy.com/growthcharts/index.html (Keep Kids Healthy, 2009).
s. Refer to a physician and a dietitian a child who is underweight for any reason. Good nutrition is extremely important for children to ensure sufficient growth and development of all body systems.
• Work with the child and parent to develop an appropriate weight gain plan. The goal with a child is sometimes to maintain existing weight as the body grows taller.
• Recognize that a large percentage of girls and teenagers are dieting, which can result in nutritional problems.
• Screen for protein-energy malnutrition in elderly clients regardless of setting. Use a screening tool such as the Mini Nutritional Assessment (Kaiser et al, 2010). Malnutrition is common in the elderly population, and malnutrition increases the risk for illness and death in the elderly (DiMaria-Ghalili & Amella, 2008; Kaiser et al, 2010; Saka et al, 2010). EB: Malnutrition was found to be a predisposing cause to hip fracture (Stolee et al, 2009).
• Screen for dysphagia in all elderly clients. EB: Dysphagia is common in the elderly for multiple reasons and is associated with onset of pneumonia (Serra-Prat et al, 2012). See care plan Impaired Swallowing.
• Recognize that geriatric clients with moderate or severe cognition impairment have a significant risk of developing malnutrition. EBN: A study demonstrated that elders with cognitive impairment had a risk of developing malnutrition, irrespective of living and housing arrangement (Fagerstrom et al, 2011).
s. Interpret laboratory findings cautiously. Watch the color of urine for an indication of fluid balance; darker urine demonstrates dehydration. CEB: Because it is correlated to urine specific gravity and urine osmolality, observing urine color is a low-cost method of monitoring dehydration (Wakefield et al, 2002). Compromised kidney function makes reliance on blood and urine samples for nutrient analyses less reliable in the elderly than in younger persons.
• Recognize that constipation is a common problem with the elderly; therefore, they avoid many types of food for fear of problems with their bowel regimen. CEB: Studies indicate that daily consumption of fruit and fiber-rich porridge has a positive effect on stool frequency and consistency when compared to laxative use (Wisten, 2005). If constipation is present, please refer to the interventions and rationales in the Constipation care plan.
• Consider using dining assistants, trained non-nursing staff, to provide feeding assistance care in extended care facilities to ensure adequate time for feeding clients as needed. EBN: A study found that dining assistants spent more time assisting residents, and the quality of care was comparable to that of nurse aides (Bertrand et al, 2011).
• Consider offering clients healthy snacks twice a day instead of nutritional supplements. EB: A research study demonstrated that clients were more likely to eat the snacks, and the snacks were less expensive than the supplement (Simmons, Zhuo, & Keeler, 2010).
• Encourage client to increase intake of protein, unless medically contraindicated by organ failure. Aim for 1.5 g of protein per kilogram of body weight. Increased protein is thought to increase muscle protein anabolism and help decrease the development of progressive muscle loss, sarcopenia, with aging. Combining increased protein with resistance exercises is even more effective in maintaining or increasing muscle. Clients taking a high-protein supplement had reduced complications, reduced readmissions to the hospital, improved grip strength, and increased protein intake along with increased energy (Cawood, Elia, & Stratton, 2011).
• Encourage physical activity throughout the day. CEB & EB: Exercise is vital for seniors and may improve oral food and fluid consumption during meals in nursing home residents (Shepherd, 2009; Simmons, 2004).
• Assess intake of components of bone health: calcium intake; the elderly adult needs 1200 mg of calcium and 800 IU of vitamin D (Institute of Medicine, 2010; Lutz & Przytulski, 2010).
• Monitor for onset of depression. Malnutrition is commonly found with depression in the elderly, but malnutrition also may cause depression in the elderly (Smith, 2008).
• Provide a restful, homelike environment during meals where clients are treated with respect and are encouraged to maintain autonomy as they are able. CEB: A study of dementia clients conducted in extended care facilities found that when caregivers were given courses on and expected to follow these guidelines—maintaining client’s integrity, interacting with client in an attentive manner, and providing a calmer, homelike atmosphere—the client gained weight (Mamhidir et al, 2007).
• Recommend to families that enteral feedings may or may not be indicated for clients with dementia; instead use hand-feeding assistance, modified food consistency as needed, or environmental alterations (Chang & Roberts, 2011; Easterling & Robbins, 2008). CEB: Research has demonstrated that tube feedings in this population do not prevent malnutrition or aspiration, improve survival, or reduce infections. Instead there is an increased risk for aspiration pneumonia (Keithley & Swanson, 2004). For strategies for feeding clients with dementia, please refer to the article by Chang and Roberts (2011).
Note: If the client is unable to feed self, refer to Nursing Interventions and Rationales for Feeding Self-Care deficit. If client has impaired physical function, malnutrition, depression, and cognitive impairment, please refer to care plan on Adult Failure to Thrive.
• The preceding interventions may be adapted for home care use.
• Screen for malnutrition using the Malnutrition Universal Screen Tool (MUST), which is simple and can be done rapidly. MUST is evidence based, and the results are reproducible to identify malnourished clients in the home (Scott, 2008). EB: A study found that in addition to being helpful in identifying malnutrition, use of the MUST tool with an accompanying MUST training course for health care professionals resulted in better nutrition in clients in the community (Kennelly et al, 2010).
• Monitor food intake. Instruct the client in intake of small frequent meals of foods with increased calories and protein.
• Assess clients’ willingness to eat; fashion interventions accordingly. CEB: Older adults reported that factors influencing appetite included mood, personal value, wholesomeness, food (preparation, consistency, and freshness), pleasantness of eating environment, and meal companionship (Wikby & Fagerskiold, 2004).
s. Assess the client for depression. Refer for mental health services as indicated. Decreased appetite with weight loss is part of the syndrome of depression. Return of appetite is unlikely unless the underlying depression is treated.
• Consider social factors that may interfere with nutrition (e.g., lack of transportation, inadequate income, lack of social support).
s. Monitor the effect of total parenteral nutrition (TPN) as ordered by physician, and appropriate including weight, blood glucose levels, electrolytes, symptoms of fluid overload or deficit, and symptoms of infection at entry site of catheter (Gorski, 2008).
Client/Family Teaching and Discharge Planning:
• Help the client/family identify the area to change that will make the greatest contribution to improved nutrition.
• Build on the strengths in the client’s/family’s food habits. Adapt changes to their current practices.
• Select appropriate teaching aids for the client’s/family’s background.
• Implement instructional follow-up to answer the client’s/family’s questions.
• Recommend that clients utilize dietary supplements such as vitamins and minerals only after consulting with their primary care practitioner (Mayo Clinic Health Letter, 2012). EB: A large study performed on women found that those who took more supplements had an increased risk of death, especially with intake of multivitamins, vitamin B6, folic acid, iron, magnesium, zinc, and copper. Calcium seemed to decrease the risk of death (Mursu et al, 2011). A systematic review found that with the possible exceptions of vitamin D and omega-3 fatty acids, there are no data to support the widespread use of dietary supplements in westernized populations; indeed, many of these supplements may be harmful (Marik & Flemmer, 2012).
• Suggest community resources as suitable (food sources, counseling, Meals on Wheels, senior centers).
• Teach the client and family how to manage tube feedings or parenteral therapy at home as needed.
References
Adkins, S.M. Recognizing and preventing refeeding syndrome. Dimen Crit Care Nurs. 2009;28(2):53–60.
Bertrand, R.M., et al. The nursing home dining assistant program. Gerontol Nurs. 2011;37(2):34–43.
Cawood, A.L., Elia, M., Stratton, R.J. Systematic review and meta-analysis of the effects of high protein oral nutritional supplements. Ageing Res Rev. 2012;11(2):278–296.
Chang, C.C., Roberts, B. Strategies for feeding patients with dementia. Am J Nurs. 2011;11(4):36–44.
DiMaria-Ghalili, R.A., Amella, E. The Mini nutritional assessment: this tool can identify malnutrition in older adults before changes in biochemistry or weight are evident. Am J Nurs. 2008;108(2):50–54. [57–60].
Dunne, J.L., Dahl, W.J. A novel solution is needed to correct low nutrient intakes in elderly long-term care residents. Nutr Rev. 2007;65(3):135–139.
Dwyer, J. Nutrient requirements and dietary assessment. In Longo D.L., et al, eds.: Harrison’s principles of internal medicine, ed 18, New York: McGraw-Hill, 2011.
Easterling, C.S., Robbins, E. Dementia and dysphagia. Geriatr Nurs. 2008;29(4):275–285.
Fagerstrom, C., et al. Malnutrition and cognitive impairment among people 60 years of age and above living in regular housing and in special housing in Sweden: a population-based cohort study. Int J Nurs Stud. 2011;48(7):863–871.
Gerasimidis, K., et al. Performance of the novel Paediatric Yorkhill Malnutrition Score (PYMS) in hospital practice. Clin Nutr. 2011;30(4):430–435.
Gorski, L.A. Total parenteral nutrition administration. In: Ackley B., et al, eds. Evidence-based nursing care guidelines: medical-surgical interventions. Philadelphia: Mosby, 2008.
Gout, B., Barker, L., Crowe, T. Malnutrition identification, diagnosis and dietetic referrals: are we doing a good enough job? Nutr Dietetics. 2009;66:206–211.
Hallpike, B. Promoting good nutrition in patients with dementia. Nurs Stand. 2008;22(29):37–43.
Institute of Medicine, Dietary reference intakes for calcium and vitamin D 2010 http://www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D/~/media/Files/Report%20Files/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D/calciumvitd_lg.jpg [Retrieved Sept 19, 2012, from].
Johansson, Y., et al. Malnutrition in a home-living older population: prevalence, incidence, and risk factors. A prospective study. J Clin Nurs. 2009;18(9):1354–1364.
Kaiser, M., et al. Frequency of malnutrition in older adults: a multinational perspective using the Mini Nutritional Assessment. J Am Geriatr Soc. 2010;58(9):1734–1738.
Keep Kids Healthy, Children’s growth charts 2009 http://www.keepkidshealthy.com/growthcharts/index.html [Retrieved May 24, 2012, from].
Keithley, J.K., Swanson, B. Enteral nutrition: an update on practice recommendations. Medsurg Nurs. 2004;13(2):131.
Kennelly, S., et al. An evaluation of a community dietetics interventions on the management of malnutrition for healthcare professionals. J Hum Nutr Dietetic. 2010;23(6):567–574.
Klein, S. Protein-energy malnutrition. In Goldman L., Schafer A., eds.: Goldman’s Cecil medicine, ed 24, St Louis: Saunders, 2011.
Lutz, C.A., Przytulski, K.R. Nutrition and diet therapy, ed 5. Philadelphia: FA Davis; 2010.
Mamhidir, A., et al. Weight increase in patients with dementia, and alteration in meal routines and meal environment after integrity promoting care. J Clin Nurs. 2007;16:987–996.
Marik, P.E., Flemmer, M. Do dietary supplements have beneficial health effects in industrialized nations: what is the evidence? JPEN J Parenter Enteral Nutr. 2012;36(2):159–168.
Mayo Clinic Health Letter: Risks of vitamin supplements, March, 2012.
McClave, S., et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2009;33(3):277–316.
Milne, A.C., et al. Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane Database Syst Rev. (2):2009. [CD003288].
Mursu, J., et al. Dietary supplements and mortality rate in older women: the Iowa Women’s Health Study. Arch Intern Med. 2011;171(18):1626–1632.
O’Meara, D., et al. Evaluation of delivery of enteral nutrition in critically ill patients receiving mechanical ventilation. Am J Crit Care. 2008;17(1):53–61.
O’Regan, P. Nutrition for patients in hospital. Nurs Stand. 2009;23(23):35–41.
Racco, M. Nutrition in the ICU. RN. 2009;72(1):26–30.
Saka, B., et al. Malnutrition in the elderly and its relationship with other geriatric syndromes. Clin Nutr. 2010;29(6):745–748.
Scott, A. Screening for malnutrition in the community: the MUST tool. Br J Community Nurs. 2008;13(9):406–412.
Serra-Prat, M., et al. Oropharyngeal dysphagia as a risk factor for malnutrition and lower respiratory tract infection in independently living older persons: a population-based prospective study. Age Ageing. 2012;41(3):376–381.
Shay, L.E., et al. Adult weight management: translating research and guidelines into practice. J Am Acad Nurse Pract. 2009;21(4):197–206.
Shepherd, A. Nutrition through the life span. Part 3: adults aged 65 years and over. Br J Nurs. 2009;18(5):301–307.
Simmons, S. Effects of an exercise and scheduled toileting intervention on appetite and constipation in nursing home residents. J Nutr Health Aging. 2004;8(2):116–121.
Simmons, S.F., et al. Feeding guideline. In: Ackley B., ed. Evidence-based nursing care guidelines: medical-surgical interventions. Philadelphia: Mosby, 2008.
Simmons, S.F., Osterweil, D., Schnelle, J.F. Improving food intake in nursing home residents with feeding assistance: a staffing analysis. J Gerontol A Biol Sci Med Sci. 2001;56(12):M790–M794.
Simmons, S.F., Schnelle, J.F. Individualized feeding assistance care for nursing home residents: staffing requirements to implement two interventions. J Gerontol A Biol Sci Med Sci. 2004;59(9):M966–M973.
Simmons, S.F., Zhuo, X., Keeler, E. Cost-effectiveness of nutrition interventions in nursing home residents: a pilot intervention. J Nutr Health Aging. 2010;14(5):367–372.
Smith, A. Nutrition in care homes: going back to the basics. Nurs Resident Care. 2008;10(2):68–72.
Somanchi, M., Tao, X., Mullin, G.E. The facilitated early enteral and dietary management effectiveness trial in hospitalized patients with malnutrition. JPEN J Parenter Enteral Nutr. 2011;35(2):209–216.
Stolee, P., et al. Risk factors for hip fracture in older home care clients. J Gerontol Ser A Biol Sci Med Sci. 2009;64(3):403–410.
United States Department of Agriculture, Supertracker, my food, my fitness, my health 2010 https://www.choosemyplate.gov/SuperTracker/default.aspx [Accessed May 25, 2012, from].
Wakefield, B., et al. Monitoring hydration status in elderly veterans. West J Nurs Res. 2002;24:132.
White, J., Guenter, P., Gordon, J. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition. J Acad Nutr Dietetics. 2012;112:730–738.
Wikby, K., Fagerskiold, A. The willingness to eat: an investigation of appetite among elderly people. Scand J Caring Sci. 2004;18:120.
Wisten, A. Fruit and fiber (Pajala porridge) in the prevention of constipation. Scand J Caring Sci. 2005;19(1):71–76.
Risk for imbalanced Nutrition: more than body requirements
NANDA-I
Risk Factors
Concentrating food at the end of day; dysfunctional eating patterns; eating in response to external cues (e.g., time of day, social situation); eating in response to internal cues other than hunger (e.g., anxiety); higher baseline weight at beginning of each pregnancy; observed use of food as comfort measure; observed use of food as reward; pairing food with other activities; parental obesity; rapid transition across growth percentiles in children; reported use of solid food as major food source before 5 months of age
NIC, NOC, Client Outcomes, Nursing Interventions, Client/Family Teaching and Discharge Planning, Rationales, and References
See care plan for Imbalanced Nutrition: more than body requirements.
Imbalanced nutrition: more than body requirements
NANDA-I
Defining Characteristics
Concentrating food intake at the end of the day; dysfunctional eating pattern (e.g., pairing food with other activities); eating in response to external cues (e.g., time of day, social situation); eating in response to internal cues other than hunger (e.g., anxiety); sedentary activity level; triceps skin fold greater than 25 mm in women, greater than 15 mm in men, weight 20% over ideal for height and frame
NOC (Nursing Outcomes Classification)
Client Outcomes
Client Will (Specify Time Frame)
• State pertinent factors contributing to weight gain
• Identify behaviors that remain under client’s control
• Design dietary modifications to meet individual long-term goal of weight control
• Lose weight in a reasonable period (1 to 2 lb per week)
• Incorporate increased exercise requiring energy expenditure into daily life
NIC (Nursing Interventions Classification)
Eating Disorders Management, Nutrition Management, Nutritional Counseling, Weight Management, Weight Reduction Assistance
Nursing Interventions and Rationales
• Ask the client to keep a 1- to 3-day food diary where everything eaten or drunk is recorded. EB: A study found that use of a personal digital assistant for self-monitoring of food intake was more effective than use of a paper record, yet both groups had a similar weight loss (Acharya et al, 2011).
• Advise the client to measure food periodically. Help the client learn usual portion sizes. Measuring food alerts the client to normal portion sizes. Estimating amounts can be extremely inaccurate. EB: A study demonstrated that obese people had significantly larger portion sizes, and they ate later in the day (Berg et al, 2009).
• Help the client determine his or her body mass index (BMI). Use a chart or a website such as http://www.cdc.gov/healthyweight/assessing/bmi/index.html (CDC, 2011). A normal BMI is 20 to 25; 26 to 29 is overweight; and a BMI of greater than 30 is obese. Clients with increased muscle mass may be labeled overweight, when in reality they are very physically fit. Also, clients who have lost large amounts of muscle mass may be in the healthy range, when in reality they may be malnourished (Camden, 2009). EB: An analysis of 57 studies demonstrated that mortality was lowest for people with a BMI of 22.5 to 25. Each 5-unit increase above a BMI of 25 resulted in an increased mortality rate by 30% (Whitlock et al, 2009).
• Recommend the client follow the U.S. Dietary Guidelines to determine foods to eat, which can be found at http://www.cnpp.usda.gov/DietaryGuidelines.htm. Dietary guidelines are written by national experts and are based on research in nutrition (USDA, 2010).
• Recommend the client use the Super Tracker, which is available at http://www.choosemyplate.gov/supertracker-tools/supertracker.html, to plan his/her diet, determine the number of calories, evaluate the foods that he/she has eaten, and gain more information on how to eat in a healthy fashion. To lose weight, the client must eat fewer calories, or expend more calories, or preferably do both (Academy of Nutrition and Dietetics, 2012).
• Recommend that clients lose weight slowly, no more than 1 to 2 lb per week, based on a healthy eating pattern and increased exercise. Slower weight loss is generally more likely to be lasting weight loss. It is important that increased activity be included to help burn more calories and to give the client all the benefits of exercise.
• Demonstrate the use of food labels to make healthful choices. Alert the client/family to focus on serving size, total fat, and simple carbohydrate. The standardized food label in bold type simplifies the search for information. Saturated fats and sugars contribute the least to a healthful diet and the most to excessive calorie intake (Lutz & Przytulski, 2011).
Psychological Aspects of Obesity
• Refer the client with binge eating for cognitive-behavioral therapy. EB: Many studies have shown the benefit of cognitive-behavioral therapy to decrease binge eating or excessive eating and to decrease weight (Rossini et al, 2011; Shaw, O’Rourke, & Mar, 2009; Vanderlinden et al, 2012).
s. Watch the client for signs of depression: flat affect, poor sleeping habits, lack of interest in life. Refer for counseling/treatment as needed. Depression is found in a large percentage of obese persons (Camden, 2009). EB: A study of obese people found that they were four times as likely to be depressed as the general population (Grossniklaus et al, 2010).
Pattern of Dietary Intake
• Recommend the client eat a healthy breakfast every morning. CEB: A study demonstrated that people who skipped breakfast were 450 times more likely to be obese (Ma et al, 2003). A study found that men on a weight reduction diet who received more protein for breakfast had increased satiety that lasted during the day (Leidy et al, 2009).
• Recommend the client avoid eating in fast food restaurants. CEB: A 15-year study demonstrated that people who often eat fast foods gain an average of 10 lb more than those who eat fast food less often, and were two times more likely to develop insulin resistance, which can lead to diabetes (Pereira, Kartashov, & Ebbeling, 2005).
• Recommend the client learn about and eat a low glycemic diet. This is a diet that maintains a steady blood sugar, eating foods that are less likely to elevate the blood sugar rapidly, and then have the blood sugar drop and stimulate hunger. EB: A Cochrane review found that clients who ate a low glycemic diet had an increased weight loss versus eating a regular diet (Thomas et al, 2009).
• For information about how to eat healthy and lose weight regarding carbohydrates, protein, and fat, please refer to the care plan Readiness for enhanced Nutrition.
Recommended Foods/Fluids
• Encourage the client to increase intake of vegetables and fruits to at least five servings per day, preferably nine servings per day. Vegetables are low in calories: 10 to 50 calories per serving, yet packed with vitamins, minerals, and phytochemicals, which can protect from disease (Liebman & Hurley, 2009).
• Encourage the client to eat at least three whole grain servings per day, preferably more. EB: A review of studies found strong evidence that eating whole grains is associated with a decreased BMI and reduced risk of being overweight (Williams, Grafenauer, & O’Shea, 2008).
• Encourage the client to stop drinking sugar-sweetened beverages of all kinds, including sodas, lemonade, fruit juice, sweetened tea, vitamin drinks, energy drinks, and sports beverages. Instead encourage the client to drink water, or water with unsweetened fruit in it. EB: Studies demonstrated that, when compared to diet drinks, sugary drinks increase the visceral fat, which expands waistlines and drives insulin resistance predisposing to type 2 diabetes and heart disease (Hu & Malik, 2010; Odegaard et al, 2012). EB: Another study demonstrated that increased intake of water in place of sugar-sweetened beverages helped decrease the onset of type 2 diabetes (Pan et al, 2012).
• Evaluate the client’s usual intake of fiber. Recommended intake is 25 g per day for women and 38 g per day for men. Increase intake of whole grains, beans, fruits, and vegetables to obtain needed fiber. In general, high-fiber foods take longer to eat, increase satiety, and contain fewer calories than most other foods (Slavin, 2008). EB: Increased dietary fiber was associated with lower body weight and waist-to-hip ratios; decreased fiber ingestion predicted weight gain more strongly than did fat consumption (Slavin, 2008).
• Discuss the possibility of using a primarily plant-based or vegetarian diet to lose weight. CEB: A systematic review demonstrated that the weight and BMI of vegetarians was on average 3% to 20% lower than that of nonvegetarians (Berkow & Barnard, 2006).
• Recommend client increase intake of water to at least 2000 mL or 2 quarts per day. A guideline is 1 to 1.5 mL of fluid per each calorie needed, so an average intake would be between 2000 and 3000 mL/day, or at least 8 cups of fluid. CEB: The adequate intake recommendation is 3 L for the 19- to 30-year-old male and 2.2 L for the 19- to 30-year-old female (Institute of Medicine, 2004).
• For more information on healthy eating, refer to Nursing Interventions for Readiness for enhanced Nutrition.
Behavioral Methods for Weight Loss
• Familiarize the client with the following behavior modification techniques:
Self-monitoring of food intake, including keeping a food and exercise diary
Controlling stimuli that cause overeating, such as watching television with frequent food-related commercials
Limiting food intake to one site in the home
Sitting down at the table to eat
Planning food intake for each day
Rearranging the schedule to avoid inappropriate eating
Avoiding boredom that results in eating; keeping a list of activities on the refrigerator
For a party, eating before arriving, sitting away from the snack foods, and substituting lower-calorie beverages for alcoholic ones
Deciding beforehand what to order in a restaurant
Bringing only healthy foods into the house to decrease temptation
Slowing mealtime by swallowing food before putting more food on the utensil, pausing for a minute during the meal and attempting to increase the number of pauses, and trying to be the last one to finish eating
Taking fewer bites of food, and chewing food more thoroughly before swallowing. EB: A study found that obese men took more bites of food and chewed less than lean men (Li et al, 2011).
Drinking a glass of water before each meal; taking sips of water between bites of food
Making an agreement with oneself or a significant other for a meaningful reward and not rewarding oneself with food
Changing one’s mindset, as in control of eating behavior
Practicing relaxation techniques
Behavior methods of losing weight are diverse and effective for weight loss through developing methods to control eating behavior, changing habits, and mindset (Lutz & Przytulski, 2011). EB: Behavioral-based treatments are safe and effective for weight loss (LeBlanc et al, 2011). EB: A study found that behavior treatment that was done either in person or remotely through computer teaching, email, and the phone resulted in a significant loss of weight for obese clients, versus a control group (Appel et al, 2011). A Cochrane review found that behavioral therapy used independently as a stand-alone therapy resulted in significant weight loss (Shaw, O’Rourke, & Mar, 2009).
Physical Activity
s. Determine reasons why the client would be unable to participate in an exercise program; refer for evaluation by a primary care practitioner as needed. Encourage activity to help with weight loss.
• Encourage the client to begin an exercise program, walking, swimming, dancing, running, use of the elliptical machine, and more. EB: A Cochrane review found that exercise decreases body weight and cardiovascular disease risk factors in people who are overweight or obese, especially when combined with diet, and that exercise improves health even if no weight is lost (Shaw et al, 2009).
• Recommend the client begin a walking program using a pedometer. For further information on a walking program refer to the care plan Sedentary Lifestyle. CEB: A study demonstrated that in middle-aged women, those who walked more had lower BMIs, and that women who walked 10,000 or more steps per day were in the normal range for BMI (Thompson et al, 2004).
• Encourage the client to engage in both aerobic exercise and strength training. EB: A study demonstrated that aerobic training of walking 12 miles per week at a vigorous pace using treadmills, elliptical trainers, or stationary bicycles versus strength training three times per week was associated with loss of visceral fat, the most harmful place for fat to reside and subcutaneous fat, whereas strength training caused loss of subcutaneous fat only (Li et al, 2011).
• Work with parents of the overweight child by encouraging the following behaviors:
Emphasize providing good food, not depriving children of food. Trying to get children to eat less or move more for weight control generally backfires and makes the child preoccupied with food and unwilling to move unless forced.
Accept the child’s natural size and shape; the child needs the parents’ unconditional love.
Involve the child in helping plan menus, and doing cooking and preparation as appropriate for the child’s age.
These methods can help children who are overweight without causing harm to the child.
• Determine the child’s BMI. A BMI chart for children and teens is available from the Centers for Disease Control and Prevention (CDC) at www.cdc.gov/nccdphp/dnpa/bmi/bmi-for-age.htm. EB: Research has demonstrated that kids who are overweight or obese have a higher risk for being overweight or obese as adults (Field, Cook, & Gillman, 2005).
• Work with the child and parent to develop an appropriate weight maintenance plan, including behavioral methods of weight loss, as well as increased activity. The goal with a child is often to maintain existing weight as the body grows taller. EB: A Cochrane review showed that combined behavioral lifestyle interventions are more effective than self-help or other standard programs and can lead to a significant reduction in obesity (Oude Luttikhuis, Baur, & Jansen, 2009).
• Work with the parent to change the food that is available in the home, eliminating sugary drinks and foods with a high saturated fat or trans fat content. Foods with increased sugar cause dental cavities, are empty calories for the child, and can cause obesity; high-fat foods with saturated fat and trans fats cause high cholesterol levels and obesity (Kline, 2009).
• Encourage child to increase the amount of walking done per day; if child is willing, ask him or her to wear a pedometer to measure number of steps. EB: A study demonstrated that the recommended number of steps per day to have a healthy body composition for the 6- to 12-year-old is 10,000 to 13,000 steps for a girl and 12,000 to 16,000 steps for a boy. Evidence shows that adolescents steadily decrease steps/day until approximately 8000 to 9000 steps/day are observed in 18-year-olds (Tudor-Locke et al, 2011).
• Recommend that parents do not use food as a reward for good behavior, especially foods that are concentrated sources of sugar or fat. Avoid using foods as a reward, especially high-calorie foods. Making them a reward may only make them more desirable.
• Recommend the child decrease television viewing, watching movies, and playing video games. Ask parents to limit television to 1 to 2 hours per day maximum. EB: A study demonstrated that watching television was associated with eating unhealthy snacks (Lipsky & Iannotti, 2012). A Cochrane review found that spending less time in “screen type” activities was helpful for weight loss for children (Waters et al, 2011).
• Assess changes in lifestyle and eating patterns. Energy needs decrease an estimated 5% per decade after the age of 40 years, but often eating patterns remain unchanged from youth.
• Assess fluid intake. Recommend routine drinks of fluids regardless of thirst. Thirst sensation becomes dulled in the elderly.
• Observe for socioeconomic factors that influence food choices (e.g., inadequate funds or cooking facilities). Even those on restricted budgets and with limited facilities can be helped to choose food sources for a balanced diet.
• Recognize that it is generally not appropriate to have an elderly client on a calorie-restrictive diet. Once elderly, clients deserve to eat and not be hungry. EB: Strength training and dietary modifications can improve body composition, muscle strength, and physical function in overweight and obese older adults (Straight et al, 2012). Loss of muscle (sarcopenia) occurs with normal aging; when paired with excessive fat, it leads to increased weakness and disability (Jarosz & Bellar, 2009).
• Recognize that the BMI’s accuracy is different for some ethnic groups. Blacks have 2% to 5% less body fat than whites, so it is suggested that the BMI cutoff number should be higher in blacks. Asians and Hispanics have more fat, so BMI cutoff numbers should be lower (Jackson et al, 2009).
• Use cultural beliefs, norms, and values of the client when teaching information on nutrition and weight loss. EB: A pilot study of a behavior program designed for Mexican American women seeking weight loss found that use of the Spanish language, culturally appropriate foods, and a plan built on the beliefs and traditions of the culture resulted in a significant weight loss for the participants (Lindberg et al, 2012).
• Assess for the influence of cultural beliefs, norms, and values on the client’s ideal of acceptable body weight and body size. EB: A study conducted of Ebony, a popular African American magazine, found that the women pictured were more likely to be of normal body size, as opposed to very thin models, and reinforced the idea that African American women have less dissatisfaction with their bodies than other racial/ethnic groups (Thompson-Brenner, Boisseau, & St Paul, 2011).
• Discuss with the client those aspects of his or her diet that will remain unchanged, and work with the client to adapt cultural core foods.
Client/Family Teaching and Discharge Planning:
• Utilize the motivational interviewing technique when working with clients to promote healthy eating and weight loss. EB: A pilot study with use of motivational interviewing in women found it resulted in a significant weight loss (Low et al, 2012). A review found that use of motivational interviewing was effective in causing weight loss (Armstrong et al, 2011).
• Inform the client about the health risks associated with obesity, which include cancer, diabetes, heart disease, strokes, hypertension, gastroesophageal reflux, gallstones, osteoarthritis, and venous thrombosis (Camden, 2009).
• Recommend the client weigh self frequently, ideally every day. A systematic review found that clients who weighed themselves frequently had moderate weight loss and less weight regain (Vanwormer et al, 2008).
• Inform the client and family of the disadvantages of trying to lose weight by dieting alone, and encourage the client to include exercise in the weight loss plan. Resting metabolic rate is decreased as much as 45% with extreme calorie restriction. The decrease persists after the diet period has ended, which leads to the “yo-yo effect.” With a reduced-calorie diet alone, as much as 25% of the weight lost can be lean body mass rather than fat. Resting energy expenditure is positively related to lean body mass (Lutz & Przytulski, 2011). EB: A meta-analysis found that diet plus exercise resulted in significantly greater weight loss than a diet-only intervention for weight loss (Wu, Gao, & Chen, 2009).
• Recommend the client receive adequate amounts of sleep. EB: A review found that decreased sleep was associated with increased obesity in both children and adults (Van Cauter & Knutson, 2008).
References
Academy of Nutrition and Dietetics, Back to basics for healthy weight loss 2012 http://www.eatright.org/Public/content.aspx?id=6847 [Retrieved Sept 19, 2012, from].
Acharya, S.D., et al. Using a personal digital assistant for self-monitoring influences diet quality in comparison to a standard paper record among overweight/obese adults. J Am Diet Assoc. 2011;111(4):583–588.
Appel, L.J., et al. Comparative effectiveness of weight-loss interventions in clinical practice. N Engl J Med. 2011;365(21):1959–1968.
Armstrong, M.J., et al. Motivational interviewing to improve weight loss in overweight and/or obese patients: a systematic review and meta-analysis of randomized controlled trials. Obes Rev. 2011;12(9):709–723.
Berg, C., et al. Eating patterns and portion size associated with obesity in a Swedish population. Appetite. 2009;52(1):21–26.
Berkow, S.E., Barnard, N. Vegetarian diets and weight status. Nutr Rev. 2006;64(4):175–188.
Camden, S. Obesity: an emerging concern for patients and nurses. Online J Issues Nurs. 2009;14(1):5–17.
Centers for Disease Control and Prevention (CDC), Healthy weight, it is not a diet, it is a lifestyle. BMI calculator 2011 http://www.cdc.gov/healthyweight/assessing/bmi/index.html [Retrieved June 10, 2012, from].
Field, A.E., Cook, N.R., Gillman, M.W. Weight status in childhood as a predictor of becoming overweight or hypertensive in early adulthood. Obes Res J. 2005;13(1):163.
Grossniklaus, D., et al. Psychological factors are important correlates of dietary pattern in overweight adults. J Cardiovasc Nurs. 2010;25(6):450–460.
Hu, F.B., Malik, V.S. Sugar-sweetened beverages and risk of obesity and type 2 diabetes: epidemiologic evidence. Physiol Behav. 2010;100(1):47–54.
Institute of Medicine. Applications of dietary reference intakes for electrolytes and water. Washington, DC: National Academies Press; 2004.
Jackson, A.S., et al. Body mass index bias in defining obesity of diverse young adults: the Training Intervention and Genetics of Exercise Response (TIGER) study. Br J Nutr. 2009;102(7):1084–1090.
Jarosz, P. Bellar A: Sarcopenic obesity: an emerging cause of frailty in older adults. Geriatr Nursi. 2009;30(1):64–70.
Kline, A. Pediatric obesity in acute and critical care. AACN Adv Crit Care. 2009;19(1):38–46.
LeBlanc, E., et al. Screening for and management of obesity and overweight in adults. Agency for Healthcare Research and Quality (US); October 2011. [report no 11-05159-EF-1].
Leidy, H.J., et al. Increased dietary protein consumed at breakfast leads to an initial and sustained feeling of fullness during energy restriction compared to other meal times. Br J Nutr. 2009;101(6):798–803.
Li, J., et al. Improvement in chewing activity reduces energy intake in one meal and modulates plasma gut hormone concentrations in obese and lean young Chinese men. Am J Clin Nutr. 2011;94(3):709–716.
Liebman, B., Hurley, J. Rating rutabagas: not all vegetables are created equal. Nutr Action Healthletter Jan/Feb. 2009:13–15.
Lindberg, N.M., et al. A culturally-tailored weight-loss intervention for obese Mexican-American women. Clin Med Res. 2012;10(3):144.
Lipsky, L.M., Iannotti, R.J. Associations of television viewing with eating behaviors in the 2009 Health Behaviour in School-aged Children Study. Arch Pediatr Adolesc Med. 2012;166(5):465–472.
Low, K.G., et al. Testing the effectiveness of motivational interviewing as a weight reduction strategy for obese cardiac patients: a pilot study. Int J Behav Med. 2012 Feb 12. [Epub ahead of print].
Lutz, C.A., Przytulski, K.R. Nutrition and diet therapy, ed 5. Philadelphia: FA Davis; 2011.
Ma, Y., et al. Association between eating patterns and obesity in a free-living U.S. adult population. Am J Epidiomol. 2003;158(1):85.
Odegaard, A.O., et al. Sugar-sweetened and diet beverages in relation to visceral adipose tissue, Obesity (Silver Spring). 2012;20(3):689–691.
Oude Luttikhuis, H., Baur, L. Jansen H: Interventions for treating obesity in children. Cochrane Database Syst Rev. (1):2009. [CD001872].
Pan, A., et al. Plain-water intake and risk of type 2 diabetes in young and middle-aged women. Am J Clin Nutr. 2012;95(6):1454–1460.
Pereira, M.A., Kartashov, A.I., Ebbeling, C.B. Fast-food habits, weight gain, and insulin resistance (the CARDIA study): 15-year prospective analysis. Lancet. 2005;365(9453):36.
Rossini, R., et al. Effects of cognitive-behavioral treatment for weight loss in family members. J Am Diet Assoc. 2011;111(11):1712–1719.
Shaw, K., O’Rourke, A., Mar, C.D. Psychological interventions for overweight or obesity. Cochrane Database Sys Review. (2):2009. [CD003818].
Shaw, K., et al. Exercise for overweight or obesity. Cochrane Database Syst Rev. (4):2009. [CD003817].
Slavin, J.L. Position of the American Dietetic Association: health implications of dietary fiber. J Am Diet Assoc. 2008;108(10):1716–1731.
Straight, C.R., et al. Effects of resistance training and dietary changes on physical function and body composition in overweight and obese older adults. J Phys Act Health. 2012;9(6):875–883.
Thomas, D., et al. Low glycaemic index or low glycaemic load diets for overweight and obesity. Cochrane Database Syst Rev. (2):2009. [CD005105,].
Thompson-Brenner, H., Boisseau, C.L. St Paul MS: Representation of ideal figure size in Ebony magazine: a content analysis. Body Image. 2011;8(4):373–378.
Thompson, D.L., et al. Covariability in diet and physical activity in African-American girls. Obes Res. 2004;12(Suppl):S46–S54.
Tudor-Locke, C., et al. How many steps/day are enough? for children and adolescents. Int J Behav Nutr Phys Act. 2011;28(8):78.
United States Department of Agriculture (USDA), USDA U.S. dietary guidelines: executive summary 2010 http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/ExecSumm.pdf [Retrieved June 10, 2012, from].
United States Department of Agriculture (USDA), Super Tracker and other tools 2010 http://www.choosemyplate.gov/supertracker-tools/supertracker.html [Retrieved June 10, 2012, from].
Van Cauter, E., Knutson, K.L. Sleep and the epidemic of obesity in children and adults. Eur J Endocrinol. 2008;159(Suppl 1):S59–S66.
Vanderlinden, J.D., et al. A cognitive-behavioral therapeutic program for patients with obesity and binge eating disorder: short- and long-term follow-up data of a prospective study. Behav Modif. 2012 Apr 27. [Epub ahead of print].
Vanwormer, J.J., et al. The impact of regular self-weighing on weight management: a systematic literature review. Int J Behav Nutr Phys Act. 2008;5:54.
Waters, E., et al. Interventions for preventing obesity in children. Cochrane Database Syst Rev. (12):2011. [CD001871].
Whitlock, G., et al. Body-mass index and cause-specific mortality in 900,000 adults: collaborative analyses of 57 prospective studies. Lancet. 2009;373(9669):1083–1096.
Williams, P.G., Grafenauer, S.J., O’Shea, J.E. Cereal grains, legumes, and weight management: a comprehensive review of the scientific evidence. Nutr Rev. 2008;66(4):171–182.
Wu, T., Gao, X., Chen, M. Long-term effectiveness of diet-plus-exercise interventions vs. diet-only interventions for weight loss: a meta-analysis. Obes Rev. 2009;10(3):313–323.