NURSING DIAGNOSIS: Altered nutrition: less than body requirements

related to:
  1. decreased oral intake associated with:
    1. oral, pharyngeal, and esophageal pain and difficulty swallowing resulting from mucositis if it has developed
    2. anorexia resulting from factors such as depression, fear, anxiety, fatigue, discomfort, early satiety, altered sense of taste and smell, and increased levels of certain cytokines that depress appetite (e.g. tumor necrosis factor)
    3. altered mental status (can result from fluid and electrolyte imbalances, hypoxia, or tumor involvement of the brain);
  2. loss of nutrients associated with vomiting and diarrhea if present;
  3. impaired utilization of nutrients associated with:
    1. accelerated and inefficient metabolism of proteins, carbohydrates, and fats resulting from increased levels of certain cytokines (e.g. tumor necrosis factor, interleukin-1)
    2. decreased absorption of nutrients resulting from loss of intestinal absorptive surface if mucositis has developed;
  4. utilization of available nutrients by the malignant cells rather than the host.
Desired Outcome
The client will have or attain an adequate nutritional status as evidenced by:
  1. weight within or returning toward normal range for client
  2. normal BUN and serum prealbumin, albumin, and transferrin 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. significant weight loss (loss of 5% in one month, 7.5% in 3 months, or 10% in 6 months)
    2. abnormal BUN and low serum prealbumin, albumin, and transferrin levels
    3. weakness and fatigue
    4. sore, inflamed oral mucous membrane
    5. pale conjunctiva.
  2. Monitor percentage of meals and snacks client consumes. Report a pattern of inadequate intake.
  3. Implement measures to maintain or promote an adequate nutritional status:
    1. perform actions to improve oral intake:
      1. implement measures to reduce nausea and vomiting (see Diagnosis 4, action c)
      2. implement measures to reduce oral, pharyngeal, esophageal, and abdominal pain (see Diagnosis 3, action d.4)
      3. implement measures to assist client to adjust psychologically to the diagnosis of cancer and treatment with chemotherapy (see Diagnoses 10, actions c-j and 11, action b)
      4. implement measures to compensate for taste alterations that might be present:
        1. encourage client to select fish, cold chicken, eggs, and cheese as protein sources if beef or pork tastes bitter or rancid
        2. provide meat for breakfast if aversion to meat tends to increase as day progresses
        3. add extra sweeteners to foods if acceptable to client
        4. experiment with different flavorings, seasonings, and textures
        5. serve food warm to stimulate sense of smell
        6. provide client with plastic rather than metal eating utensils if metallic taste is present
      5. if client is having difficulty swallowing:
        1. implement measures to reduce the severity of stomatitis and/or relieve dryness of the oral mucous membrane (see Diagnosis 5, actions b and c)
        2. assist client to select foods that require little or no chewing and are easily swallowed (e.g. custard, eggs, canned fruit, mashed potatoes)
        3. avoid serving foods that are sticky (e.g. peanut butter, soft bread, honey)
        4. moisten dry foods with gravy or sauces
      6. increase activity as tolerated (activity usually promotes a sense of well-being, which can improve appetite)
      7. obtain a dietary consult if necessary to assist client in selecting foods/fluids that are appealing and adhere to personal and cultural preferences
      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 makes it easier to chew and swallow; it also removes unpleasant tastes, which often improves the taste of foods/fluids)
      11. provide largest amount of calories and protein when appetite is the best (usually at breakfast)
      12. serve frequent, small meals rather than large ones if client is weak, fatigues easily, and/or has a poor appetite
      13. encourage significant others to bring in client's favorite foods and eat with him/her to make eating more of a familiar social experience
      14. limit fluid intake with meals (unless the fluid has high nutritional value) to reduce early satiety and subsequent decreased food intake
      15. allow adequate time for meals; reheat foods/fluids if necessary
      16. administer appetite stimulants (e.g. megestrol acetate, dronabinol) if ordered
    2. ensure that meals are well balanced and high in essential nutrients; offer high-calorie, high-protein dietary supplements (e.g. milk shakes, puddings, or eggnog made with cream or powdered milk reconstituted with whole milk; commercially-prepared dietary supplements) if indicated
    3. perform actions to control diarrhea (see Diagnosis 7, action b)
    4. administer vitamins and minerals if ordered.
  4. Perform a calorie count if ordered. Report information to dietitian and physician.
  5. Consult physician regarding 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.