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Nursing Diagnosis: Imbalanced Nutrition: more than body requirements Application of NANDA, NOC, NIC

Nursing Diagnosis: Imbalanced Nutrition: more than body requirements
Carroll A. Lutz

NANDA Definition: Intake of nutrients that exceeds metabolic needs

Defining Characteristics: Triceps skin fold >25 mm in women; triceps skin fold >15 mm in men; body weight (20% over ideal for height and frame; 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); reported or observed dysfunctional eating pattern pairing food with other activities; sedentary activity level; weight 10% over ideal for height and frame; concentrating food intake at the end of the day

Related Factors: Excessive intake in relation to metabolic need; deficient knowledge related to desirability of nutritional supplements

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
·         Weight Control
·         Nutritional Status: Nutrient Intake
·         Nutritional Status: Food and Fluid Intake Management
Client Outcomes
·         States pertinent factors contributing to weight gain
·         Identifies behaviors that remain under client's control
·         Claims ownership for current eating patterns
·         Designs dietary modifications to meet individual long-term goal of weight control, using principles of variety, balance, and moderation
·         Accomplishes desired weight loss in a reasonable period (1 to 2 pounds/week)
·         Incorporates appropriate activities requiring energy expenditure into daily life
·         Uses sound scientific sources to evaluate need for nutritional supplements
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
·         Weight Management
·         Eating Disorders Management
·         Nutrition Management
·         Nutritional Counseling, Weight Reduction Assistance
Nursing Interventions and Rationales
·         Obtain a thorough history. Refer to dietitian if client has a medical condition. The most appropriate clients for the nursing intervention of Weight Management are adults with no major health problems who require diet therapy. If a patient has a medical condition necessitating diet therapy, the assistance of a dietitian may be required (Crist, 1992).
·         Evaluate client's physiological status in relation to weight control. Refer as appropriate. Nondieting approaches focus on changing disturbed thoughts, emotions, and body image associated with obesity to help obese persons to accept themselves and resolve issues that may hinder long-term weight maintenance (Foreyt, Walker, Poston II, 1998).
·         Assess dietary intake through 24-hour recall or questions regarding usual intake of food groups. Information may not be completely accurate. Permits appraisal of client's knowledge about diet also.
·         Determine client's knowledge of a nutritious diet and need for supplements. This information is useful for developing an individualized teaching plan based on client's current state.
·         Calculate body mass index (BMI) (use this formula: weight in kg divided by height in m2 [kg/(m)2]; or use this alternate formula: weight in lb multiplied by 705, divided by height in inches, divided again by height in inches). A normal BMI is 20 to 25, 26 to 29 is overweight, and a BMI of greater than or equal to30 is defined as obesity.
·         Compute the waist to hip ratio (WHR). A WHR >0.85 in women and >1.0 in men indicates increased risk of problems related to obesity (Lutz, Przytulski, 2001).
·         Define client's healthy body weight with client, considering physiological, experiential, and cultural factors. Overweight has been viewed as an individual problem, and treatment oriented toward an individual victim-blame model, with little consideration of personal context or the influence of cultural values on behavior (Allan, 1994). Children have been included in weight management programs but their growth factor has not been factored into the equation, potentially risking future growth-related health problems. These potential risks may require the direct attention of dietitians and physicians (Crist, 1992).
·         Determine client's motivation to lose weight, whether for appearance or health benefits. Female peripheral fat pattern (gynecoid), predominant in most women, is associated with virtually no impairment of health (Allan, 1994). Often a healthier body weight is only a 5% to 10% reduction from initial body weight (Nonas, 1998).
·         Observe for situations that indicate a nutritional intake of more than body requirements. Such observations help gain a clear picture of the client's dietary habits. Overfeeding of post-trauma patients that was attributed to the lack of an interdisciplinary plan of care has been documented (Klein, Henry, 1999).
·         Suggest client keep a diary of food intake and circumstances surrounding its consumption (methods of preparation, duration of meal, social situation, overall mood, activities accompanying consumption). Self-monitoring helps the client assess adherence to self-determined performance criteria and progress toward desired goals. Self-monitoring serves an important role in the maintenance of internal standards of behavior (Fleury, 1991).
·         Adopt a weight loss plan that incorporates the client's culture and preferences. Dramatic weight loss was achieved in Hawaii with a culturally appropriate methodology (Shintani et al, 1991).
·         Advise client to measure food periodically. Measuring food alerts client to normal portion sizes. Estimating amounts can be extremely inaccurate.
·         Review client's current exercise level. With client and primary health care provider, design a long-term exercise program. A health risk appraisal should be performed on all previously sedentary individuals beginning a program of exercise (Grubbs, 1993). Exercise is important for increased energy expenditure, for maintenance of lean body mass, and as part of a total change in lifestyle (Lutz, Przytulski, 2001). In one study, 80% of the weight lost by exercisers was fat; whereas 40% of of the weight loss by dieters was lean tissue (Pritchard, Nowson, Wark, 1997). Loss of lean tissue is undesirable because muscle tissue is estimated to be as much as 70 times as metabolically active as fat tissue (Rippe, Hess, 1998). Women consuming an energy-restricted diet in addition to performing aerobic and strength training exercise lost more weight than the other study groups and slightly increased their lean muscle tissue (Rippe, Hess, 1998).
·         Establish a reasonable goal for client's body weight and for weight loss (e.g., 1 to 2 pounds/week). Height and weight tables have been criticized because they are based on middle-class white men (Allan, 1994). Because subjects in one study achieved comparable weight loss on liquid formula diets of 420, 600, or 800 kcal/day, choosing the higher energy diets may minimize adverse side effects (Foster et al, 1992).
·         Initiate a client contract that involves rewarding and reinforcing progressive goal attainment. Patient contracts provide a unique opportunity for patients to learn to analyze their behavior in relationship to the environment and to choose behavioral strategies that will facilitate learning. A series of written contracts provides a history of progress toward desired behaviors (Boehm, 1992).
·         Weigh client twice a week under the same conditions. It is important to most clients and their progress to have the tangible reward that the scale shows. Monitoring twice a week keeps the client on the program by not allowing him or her to eat out of control for a couple of days and then fast to lose weight (Crist, 1992).
·         Instruct client regarding adequate nutritional intake. A total plan permits occasional treats. Permanent lifestyle changes must occur for weight loss to be long lasting. Eliminating all treats is not sustainable. Numerous studies have demonstrated that fewer than 5% of persons who lose weight through energy restriction alone are able to maintain this weight loss for 2 years or more (Rippe, Hess, 1998). During energy restriction, a client should consume 72 to 80 g of high biological value protein per day to minimize risk of ventricular arrhythmias (Nonas, 1998).
·         Familiarize client with the following behavior modification techniques (Lutz, Przytulski, 2001):
o    Keep a food and exercise diary
o    Graph weight weekly Stimulus control
o    Limit food intake to one site in the home
o    Sit down at the table to eat
o    Plan food intake for each day
o    Rearrange schedule to avoid inappropriate eating
o    Save or reschedule everyday activities for times when you are hungry
o    Avoid boredom; keep a list of activities on the refrigerator
o    At a party: eat before you go, sit away from the snack foods, and substitute lower calorie beverages for alcoholic ones
o    Decide beforehand what to order in a restaurant Slow down eating
o    Drink a glass of water before each meal; take sips of water between bites of food
o    Swallow food before putting more food on the utensil
o    Try to be the last one to finish eating
o    Pause for a minute during your meal, and attempt to increase the number of pauses Reward yourself
o    Chart your progress
o    Make an agreement with yourself or significant other for a meaningful reward
o    Do not reward yourself with food Cognitive strategies
o    View exercise as a means of controlling hunger
o    Practice relaxation techniques
o    Imagine yourself ordering a side salad, diet dressing, low-fat milk, and a small hamburger at a fast-food restaurant
o    Visualize yourself enjoying a fresh apple in preference to apple pie
·         Encourage client to adopt an exercise program that involves 45 minutes of exercise five times/week. As exercise time increases beyond 30 minutes, there is an increased reliance on fat stores for energy (Grubbs, 1993). Moderately intense physical activity for 30 to 45 minutes 5 to 7 days/week can expend the 1500 to 2000 calories/week that appear to be necessary to maintain weight loss. Cross-sectional and longitudinal studies illustrate that persons who increase their physical activity also increase their resting metabolic rate (Rippe, Hess, 1998).
·         Assess for use of nonprescription diet aids. Ingestion of an herbal supplement (containing Ma-huang, the main plant source of ephedrine) for weight loss caused mania in a client with no history of psychiatric illness (Capwell, 1995). Clinicians should be aware that ostensibly harmless herbal remedies may have potent ingredients that are not subjected to the same scrutiny that the FDA devotes to prescription drugs (Woolf, 1994).
·         Observe for overuse of particular nutrients. Almost all nutrients given in quantities beyond a certain threshold will reduce immune responses (Chandra, 1997). Daily ingestion of 500 ml of tonic water containing 40 mg of quinine hydrochloride caused photosensitivity. Other conditions associated with tonic water are disseminated intravascular coagulation, recurrent dermatitis, fixed drug eruption, and toxic epidermal necrolysis (Wagner et al, 1994). Clients who are consuming excessive amounts of some nutrients may also be consuming less than adequate amounts of others.
·         Assess fluid intake. Recommend routine drinks of water whether thirsty or not. Thirst sensation becomes dulled in the elderly.
·         Observe for socioeconomic factors that influence food choices (e.g., funds, cooking facilities). Food choices in today's food markets are greatly enhanced, even for those on a limited budget (Love, Seaton, 1991).
·         Suggest a variety of seasonings. The ability to taste sweet, bitter, sour, and salty declines in most, but not all, older persons (Morley, 1997).
·         Encourage social involvement in activities other than eating. Energy needs decrease an estimated 5% per decade after the age of 40.
·         Recommend weight reduction changes judiciously. Weight reduction should be pursued if it is needed to treat current problems, such as diabetes mellitus or hypertension, but not to prevent new ones (Feldman, 1988).
·         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 (Leininger, 1996).
·         Assess for the influence of cultural beliefs, norms, and values on the client's ideal of acceptable body weight and body size. Ideal body weight and size may be based on cultural perceptions (Leininger, 1996). African-American women report more satisfaction than other women with body size (Miller et al, 2000). Overweight Hispanic women with high levels of binge eating and depression preferred a slimmer body ideal (Fitzgibbon et al, 1998).
·         Discuss with the client those aspects of his or her diet that will remain unchanged, and work with client to adapt cultural core foods. Aspects of the client's life that are meaningful and valuable to them should be understood and preserved without change (Leininger, 1996). Core foods are those foods which are universal, staple, important, and consistently used in the culture (Sanjur, 1995).
·         Negotiate with the client regarding the aspects of his or her diet that will need to be modified. Give and take with the client will lead to culturally congruent care (Leininger, 1996).
·         Validate the client's feelings regarding the impact of current lifestyle, finances, and transportation on ability to obtain and prepare nutritious food. Validation lets the client know that the nurse has heard and understands what was said, and it promotes the nurse-client relationship (Stuart, Laraia, 2001; Giger, Davidhizer, 1995).
Client/Family Teaching
·         Foster client's/family's input into care plan. Extrinsic motivations (such as pressure from others) may be less effective than intrinsic motivations (such as beliefs) on promoting healthful behaviors (Patterson et al, 1995).
·         Provide the client and family with information regarding the treatment plan options. Because the purpose is to obtain a permanent change in weight management, the decision regarding treatment plans should be left up to the client and family (Crist, 1992).
·         Inform the client about the health risks associated with obesity.
·         Guide the client toward changes that will make a major impact on health. Even modest weight loss contributes to diabetes and hypertension control.
·         Inform the client/family of the disadvantages of trying to lose weight by dieting alone. Resting metabolic rate is decreased as much as 45% with extreme calorie restriction. The decrease persists after the diet period has ended, leading 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 (Grubbs, 1993).
·         Teach the importance of exercise in a weight control program. A physically conditioned person uses more fat for energy at rest and with exercise than a sedentary person does (Grubbs, 1993). The majority of patients will benefit from establishing walking as a cornerstone of their physical activity program (Rippe, Crossley, Ringer, 1998).
·         Teach stress reduction techniques as alternatives to eating. The client needs to substitute healthy for unhealthy behaviors.

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