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Nursing Assessment

Mrs. Rose Santini, a 59-year-old homemaker, attends a community hospital –sponsored health fair. She

approaches the nutrition

information booth, and the clinical specialist in nutritional support

gathers a nutritional history. Mrs. Santini is very upset about her

9-kg (20-lb) weight gain. She relates to the nurse clinician that

since the death of her husband 1 month ago she has lost interest

in many of her usual physical and social activities. She no longer

attends YMCA exercise and swimming sessions and has lost contact with her couple’s bridge group. Mrs.

Santini states she is

bored, depressed, and very unhappy about her appearance. She

has a small frame and has always prided herself on her petite figure. She says her eating habits have

changed considerably. She

snacks while watching TV and rarely prepares a complete meal.

Imbalanced Nutrition: More

than body requirements related

to excess intake and decreased

activity expenditure (as evidenced by weight gain of 20 lb,

triceps skin fold greater than

normal, undesirable eating

patterns).

Weight Control [1612] as evidenced by demonstrating

■ Eats three meals each day

that result in a 500-calorie

reduction in intake.

■ Develops a physical exercise

plan that engages her in 15



to 20 minutes of exercise by

day 5.

■ Identifies eating habits that

contribute to weight gain by

day 2.

NURSING INTERVENTIONS*/SELECTED ACTIVITIES RATIONALE

Weight Reduction Assistance [1280]

Determine current eating patterns by having Mrs. Santini keep a

diary of what, when, and where she eats.

Set a weekly goal for weight loss.

Encourage use of internal reward systems when goals are accomplished.

Set a realistic plan with Mrs. Santini to include reduced food intake and increased energy expenditure.

Assist client to identify motivation for eating and internal and external cues associated with eating.

Encourage attendance at support groups for weight loss and/or

refer to a community weight control program.

Develop a daily meal plan with a well-balanced diet, reduced

calories, and reduced fat.

Increases awareness of activities and foods that contribute to excessive intake.

The desirable weight loss rate is 1 –2 pounds per week.

Goal setting provides motivation, which is essential for a successful weight-loss program.

A combined plan of calorie reduction and exercise can enhance

weight loss since exercise increases caloric utilization.

Awareness of factors that contribute to overeating will assist the

individual in planning behavior modification techniques to avoid

situations that prompt excess food consumption.



Overweight people are often nutritionally deprived. Intake must

be reduced by 500 calories per day to obtain a one-pound-perweek weight loss.

Support groups can provide companionship, increase motivation,

and offer practical solutions to problems associated with dieting.

Physical Examination

Height: 162.6 cm (5′ 4′′ )

Weight: 63.6 kg (140 lb)

Temperature: 37°C (98.6°F)

Pulse: 76 BPM

Respirations: 16/minute

Blood pressure: 144/84 mm Hg

Triceps skinfold: 21 mm

Small frame, weight in excess of

10% over ideal for height and

frame

Diagnostic Data

CBC normal, urinalysis negative,

chest x-ray negative, thyroid

profile within normal limits

Nutritional Counseling [5246]

Facilitate identification of eating behaviors to be changed.

Use accepted nutritional standards to assist Mrs. Santini in evaluating adequacy of dietary intake.

Increases individual’s awareness of those actions that contribute

to excessive intake.

Comparing the individual’s dietary history with nutritional standards will facilitate identification of

nutritional deficiencies and/or



excesses.

koz74686_ch47.qxd 11/8/06 6:09 PM Page 1278CHAPTER 47 / Nutrition 1279

NURSING CARE PLAN Nutrition continued

NURSING INTERVENTIONS*/SELECTED ACTIVITIES RATIONALE

EVALUATION

Help Mrs. Santini to consider factors of age, past eating experiences, culture, and finances in planning

ways to meet nutritional

requirements.

Discuss Mrs. Santini’s knowledge of the basic four food groups, as

well as perceptions of the needed diet modification.

Discuss food likes and dislikes.

Assist Mrs. Santini in stating her feelings and concerns about goal

achievement.

Social, economic, physical, and psychologic factors play a role in

nutrition and/or malnutrition.

Helps to determine the client’s knowledge base and identify misconceptions and/or gaps in

understanding.

Incorporating Mrs. Santini’s food preferences into the dietary plan

will promote adherence to the weight loss program.

Fear of success, failure, or other concerns may block goal achievement.

Behavior Modification [4360]

Assist Mrs. Santini to identify strengths and reinforce these.

Encourage her to examine her own behavior.

Identify the behavior to be changed in specific, concrete terms

(e.g., stop snacking in front of the TV).

Consider that it is easier to increase a behavior than to decrease a



behavior (e.g., increase activities or hobbies that involve the

hands such as sewing versus decreasing TV snacking).

Choose reinforcers that are meaningful to Mrs. Santini.

Reinforcing strengths enhances self-esteem and encourages the individual to draw on these assets

during the weight-loss program.

Involving Mrs. Santini in self-appraisal will promote identification

of behaviors that may be contributing to excessive caloric intake.

Identification of specific behaviors is essential for planning behavior modification.

Habitual behaviors are difficult to change. Breaking old habits

may be easier if viewed from the standpoint of increasing an enjoyable, healthy activity.

Positive reinforcement is not likely to be an effective part of behavior modification if the reinforcer is

meaningless to the individual.

Outcome met. Mrs. Santini kept a dietary log for 5 days and has eaten balanced meals each day,

resulting in a daily deficit of 400 to 500

calories. She is aware that she eats excessively because she is bored and depressed. She has

reestablished her former social contacts including her church bridge club. Mrs. Santini has purchased a

stationary bicycle and exercises 20 minutes daily. She enrolled in a knitting

class that meets two nights per week. She has lost 11/2 lb in the past week. As a reward, Mrs. Santini

renewed her membership to the

YMCA.

Nursing Care Plan for Hypertension

Nursing Diagnosis: Activity intolerance may be related to generalized weakness orimbalance between oxygen supply and demand.

Possibly evidenced by

Verbal report of fatigue or weaknessAbnormal heart rate or BP response to activity

Exertional discomfort or dyspneaECG changes reflecting ischemia, dysrhythmias

Desired Outcomes/Evaluation Criteria—Client WillEnduranceParticipate in necessary and desired activities.

Report a measurable increase in activity tolerance.



Demonstrate a decrease in physiological signs of intolerance.

Nursing Care Plan Intervention and Rationale:1. Assess the client’s response to activity, noting pulse rate more than 20 beats per minute

faster than resting rate; marked increase in BP (systolic increases more than 40 mm Hg ordiastolic increases more than 20 mm Hg) during and after activity, dyspnea or chest pain,

excessive fatigue and weakness, and diaphoresis, dizziness, and syncope.Rationale: Changes in baseline are helpful in assessing physiological responses to the stress

of activity and, if present, are indicators of overexertion.

2. Instruct client in energy-conserving techniques, such as using chair when showering,

sitting to brush teeth or comb hair, and carrying out activities at a slower pace.Rationale: Energy-saving techniques reduce the energy expenditure, thereby assisting in

equalization of oxygen supply and demand.

3. Encourage progressive activity and self-care when tolerated. Provide assistance asneeded.

Rationale: Gradual activity progression prevents a sudden increase in cardiac workload.

Provide assistance only as needed, which encourages independence in performing activities.

Nursing Diagnosis for Hypertension: imbalanced Nutrition:More than Body Requirements related to excessive intake in

relation to metabolic need, sedentary activity level and lifestyle,

cultural preferences

Possibly evidenced by

Weight that is 10% to 20% more than ideal for height and frameTriceps skinfold that is more than 15 mm in men and 25 mm in women, the maximum for

age and sex

Reported or observed dysfunctional eating patterns

Desired Outcomes/Evaluation Criteria—Client Will

Knowledge: Treatment Regimen

Identify correlation between hypertension and obesity.Weight Control

Demonstrate change in eating patterns, such as food choices and quantity, to attain

desirable body weight with optimal maintenance of health.Initiate and maintain individually appropriate exercise program.

Nursing Care Plan Intervention and Rationale:1. Assess client’s understanding of direct relationship between hypertension and obesity.

Rationale: Obesity is an added risk with hypertension because of the disproportion betweenfixed aortic capacity and increased cardiac output associated with increased body mass.Reduction in weight may reduce or eliminate the need for drug therapy needed to controlBP. Note: Recent research suggests that bringing weight within 15% of ideal weight canresult in a drop of 10 mm Hg in both systolic and diastolic BP (Khan et al, 2004).

2. Discuss necessity for decreased caloric intake and limited intake of fats, salt, and sugar,as indicated.



Rationale: Faulty eating habits contribute to atherosclerosis and obesity that can predispose

to hypertension and subsequent complications, such as stroke, kidney disease, and heart

failure. Excessive salt intake expands the intravascular fluid volume and may damagekidneys, which can further aggravate hypertension.

3. Determine client’s desire to lose weight.

Rationale: Motivation for weight reduction is internal. The individual must want to loseweight or the program most likely will not succeed.

4. Review usual daily caloric intake and dietary choices.

Rationale: Identifies current strengths and weaknesses in dietary program. Aids in

determining individual need for adjustment and teaching.

5. Establish a realistic weight reduction plan with the client, such as weight loss of 1 pound

per week.Rationale: Slow reduction in weight is associated with fat loss with muscle sparing andgenerally reflects a change in eating habits.

6. Rationale: Encourage client to maintain a diary of food intake, including when and where

eating takes place and the circumstances and feelings around which the food was eaten.Rationale: Provides a database for both the adequacy of nutrients eaten and the relationship

of emotion to eating. Helps focus attention on factors that client can control or change.

7. Instruct and assist client in appropriate food selections, such as implementing a diet rich

in fruits, vegetables, and lowfat dairy foods referred to as the Dietary Approaches to Stop

Hypertension (DASH) diet. Help the client identify—and thus avoid—foods high in saturatedfat, such as butter, cheese, eggs, ice cream, and meat, and those that are high incholesterol, such as whole dairy products, shrimp, and organ meats.

Rationale: Moderation and use of low-fat products in place of total abstinence from certainfood items may prevent client’s sense of deprivation and enhance commitment to achieving

health goals. Avoiding foods high in saturated fat and cholesterol is important in preventingprogressingatherogenesis. The DASH diet, in conjunction with exercise, weight loss, and limits on saltintake, may reduce or even eliminate the need for drug therapy in early stages of

hypertension (Elmer et al, 2006).

8. Refer to dietitian or weight management programs, as indicated.

Rationale: Can provide additional counseling and assistance with meeting individual dietary

needs.

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