NURSING DIAGNOSIS: Altered nutrition: less than body requirements

related to:
  1. decreased oral intake associated with:
    1. anorexia resulting from malaise, fatigue, fear, anxiety, pain, depression, and increased levels of certain cytokines that depress appetite (e.g. tumor necrosis factor [TNF])
    2. nausea, dyspnea, and cognitive impairment if present
    3. oral pain and/or dysphagia resulting from opportunistic lesions in the mouth, pharynx, and esophagus;
  2. impaired utilization of nutrients associated with:
    1. accelerated and inefficient metabolism of nutrients resulting from an increased resting energy expenditure that occurs with infection and increased levels of certain cytokines (e.g. TNF, interleukin-l)
    2. decreased absorption of nutrients if HIV and/or opportunistic infection involve the intestine;
  3. loss of nutrients associated with persistent diarrhea and vomiting if present.
Desired Outcome
The client will maintain an adequate nutritional status as evidenced by:
  1. weight within or returning toward normal range for client
  2. normal BUN and serum prealbumin, albumin, Hct, and Hb levels
  3. usual strength and activity tolerance
  4. healthy oral mucous membrane.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of malnutrition:
    1. weight significantly below client's usual weight or below normal for client's age, height, and body frame
    2. abnormal BUN and low serum prealbumin, albumin, Hct, and Hb levels
    3. weakness and fatigue
    4. sore, inflamed oral mucous membrane
    5. pale conjunctiva
    6. lower than normal anthropometric measurements such as skinfold thickness, mid-upper arm circumference (MAC), and mid-upper arm muscle circumference (MAMC).
  2. Monitor percentage of meals and snacks client consumes. Report a pattern of inadequate intake.
  3. Implement measures to maintain an adequate nutritional status:
    1. perform actions to improve oral intake:
      1. implement measures to prevent breakdown of the oral mucous membrane and promote healing of existing lesions (see Diagnosis 6, action b) in order to reduce oral/pharyngeal pain and improve swallowing
      2. implement measures to reduce fear and anxiety and assist client to adjust to and cope with the diagnosis of AIDS (see Diagnoses 13, action b and 14, action b)
      3. implement measures to reduce nausea (e.g. administer prescribed antiemetics, encourage client to eat dry foods when nauseated, avoid serving foods with an overpowering aroma)
      4. implement measures to reduce pain (see Diagnosis 4, action e)
      5. increase activity as tolerated (activity usually promotes a sense of well-being, which can improve appetite)
      6. obtain a dietary consult if necessary to assist client in selecting foods/fluids that meet nutritional needs, are appealing, and adhere to personal and cultural preferences
      7. if client is having difficulty swallowing, assist him/her to select foods that are easily chewed and swallowed (e.g. eggs, custard, macaroni and cheese, baby foods) and avoid serving foods that are sticky (e.g. peanut butter, soft bread)
      8. encourage a rest period before meals to minimize fatigue
      9. maintain a clean environment and a relaxed, pleasant atmosphere
      10. provide oral hygiene before meals (oral hygiene moistens the mouth, which may make it easier to chew and swallow; it also removes unpleasant tastes, which often improves the taste of foods/fluids)
      11. serve frequent, small meals rather than large ones if client is weak, fatigues easily, and/or has a poor appetite
      12. if client is dyspneic, place in a high Fowler's position for meals and provide supplemental oxygen therapy during meals
      13. if client's sense of taste is altered, suggest adding extra sweeteners and flavorings/seasonings to foods
      14. encourage significant others to bring in client's favorite foods and eat with him/her to make eating more of a familiar social experience
      15. assist client with meals if indicated
      16. allow adequate time for meals; reheat foods/fluids as necessary
    2. perform actions to control diarrhea (see Diagnosis 9, action d)
    3. ensure that meals are well balanced and high in essential nutrients; offer high-protein, high-calorie dietary supplements (e.g. elemental formulas, nutrient-dense candy bars and soups) if indicated
    4. consult physician or physical therapist about a progressive exercise program (exercise is necessary to promote the maintenance/buildup of lean body mass and help prevent wasting)
    5. administer the following if ordered:
      1. vitamins and minerals
      2. appetite stimulants (e.g. megestrol acetate, dronabinol)
      3. anabolic agents (e.g. growth hormone, testosterone, oxandrolone)
      4. cytokine inhibitors (e.g. thalidomide) to improve appetite and promote weight gain by suppressing TNF-a production (use of thalidomide is reserved for persons with severe HIV-related wasting).
  4. Perform a calorie count if ordered. Report information to dietitian and physician.
  5. Consult physician about an alternative method of providing nutrition (e.g. parenteral nutrition, tube feedings) if client does not consume enough food or fluids to meet nutritional needs.