Nursing Assessment Mrs. Rose Santini, a 59-year-old homemaker, attends a community hospitalsponsored 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 couples 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 12 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: 37C (98.6F) 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 individuals awareness of those actions that contribute to excessive intake. Comparing the individuals 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. Santinis 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 clients knowledge base and identify misconceptions and/or gaps in understanding. Incorporating Mrs. Santinis 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 or imbalance between oxygen supply and demand. Possibly evidenced by Verbal report of fatigue or weakness Abnormal heart rate or BP response to activity Exertional discomfort or dyspnea ECG changes reflecting ischemia, dysrhythmias Desired Outcomes/Evaluation CriteriaClient Will Endurance Participate 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 clients 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 or diastolic 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 as needed. 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 frame Triceps 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 CriteriaClient 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 clients understanding of direct relationship between hypertension and obesity. Rationale: Obesity is an added risk with hypertension because of the disproportion between fixed 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 control BP. Note: Recent research suggests that bringing weight within 15% of ideal weight can result 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 damage kidneys, which can further aggravate hypertension. 3. Determine clients desire to lose weight. Rationale: Motivation for weight reduction is internal. The individual must want to lose weight 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 and generally 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 identifyand thus avoidfoods high in saturated fat, such as butter, cheese, eggs, ice cream, and meat, and those that are high in cholesterol, such as whole dairy products, shrimp, and organ meats. Rationale: Moderation and use of low-fat products in place of total abstinence from certain food items may prevent clients sense of deprivation and enhance commitment to achieving health goals. Avoiding foods high in saturated fat and cholesterol is important in preventing progressing atherogenesis. The DASH diet, in conjunction with exercise, weight loss, and limits on salt intake, 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.