Imbalanced Nutrition: less than body requirements

Intake of nutrients insufficient to meet metabolic needs

Defining Characteristics:

• Body weight greater than or equal to20% under ideal weight; 
• pale conjunctival and mucus membranes; 
• weakness of muscles required for swallowing or mastication; 
• sore, inflamed buccal cavity; 
• satiety immediately after ingesting food; 
• reported or evidence of lack of food; 
• reported inadequate food intake less than RDA (Recommended Dietary Allowance); 
• reported altered taste sensation; 
• perceived inability to ingest food; 
• misconceptions; 
• loss of weight with adequate food intake; 
• aversion to eating; 
• abdominal cramping; 
• poor muscle tone; 
• abdominal pain with or without pathology; 
• lack of interest in food; 
• capillary fragility; 
• diarrhea and/or steatorrhea; 
• excessive loss of hair; 
• hyperactive bowel sounds; 
• lack of information; 
• misinformation

Related Factors: 
Inability to ingest or digest food or absorb nutrients because of biological, psychological, or economic factors

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

• Nutritional Status
• Nutritional Status: Food and Fluid Intake
• Nutritional Status: Nutrient Intake
• Weight Control

Client Outcomes

• Progressively gains weight toward desired goal
• Weight is within normal range for height and age
• Recognizes factors contributing to underweight
• Identifies nutritional requirements
• Consumes adequate nourishment
• Free of signs of malnutrition

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

• Nutrition Management
• Eating Disorders Management
• Electrolyte Management: Hypophosphatemia
• Enteral Tube Feeding
• Feeding
• Nutrition Therapy
• Nutritional Counseling
• Nutritional Monitoring
• Swallowing Therapy
• Weight Gain Assistance
• Weight Management

Nursing Interventions and Rationales

1. Determine healthy body weight for age and height. Refer to dietitian for complete nutrition assessment if 10% under healthy body weight or if rapidly losing weight. Legal intervention may be necessary.
Early diagnosis and a holistic team treatment of eating disorders are desirable. Of women who ran 15 to 30 miles per week, 20% to 25% had increased risk of eating disorders (Estok, Rudy, 1996). In the developed world, protein-calorie malnutrition (PCM) most often accompanies a disease process. Surveys of hospitalized children in this country revealed that 20% to 40% had PCM (Baker, 1997). Over the short term, patients involuntarily committed for treatment of eating disorders progressed as well as those seeking treatment voluntarily (Watson, Bowers, Andersen, 2000).

2. Compare usual food intake to USDA Food Pyramid, noting slighted or omitted food groups.
Milk consumption has decreased among children while intake of fruit juices and carbonated beverages has increased. A higher incidence of bone fractures in teenage girls has been associated with a greater consumption of carbonated beverages (Wyshak, 2000). Possibly also related is the substitution of soda for milk. Omission of entire food groups increases risk of deficiencies.

3. If client is a vegetarian, evaluate if obtaining sufficient amounts of vitamin B12 and iron.
Strict vegetarians may be at particular risk for vitamin B12 and iron deficiencies. Special care should be taken when implementing vegetarian diets for pregnant women, infants, children, and the elderly. A dietitian can usually furnish a balanced vegetarian diet (with adequate substitutes for omitted foods) for inpatients and can provide instruction for outpatients.

4. Assess client's ability to obtain and use essential nutrients.
Cases of vitamin D deficiency rickets have been reported among dark-skinned infants and toddlers who were exclusively breast fed and were not given supplemental vitamin D. The children resided in northern (Fitzpatrick et al, 2000), mid-south (Kreiter et al, 2000), and southern (Shah et al, 2000) states, indicating that the presence of natural sunlight does not eliminate the risk of disease.

5. Observe client's ability to eat (time involved, motor skills, visual acuity, ability to swallow various textures).
Poor vision was associated with lower protein and energy (calorie) intakes in home care clients independent of other medical conditions (Payette et al, 1995).

NOTE: If client is unable to feed self, refer to Nursing Interventions and Rationales for Feeding Self-care deficit. If client has difficulty swallowing, refer to Nursing Interventions and Rationales for Impaired Swallowing.

6. If client lacks endurance, schedule rest periods before meals and open packages and cut up food for client.
Nursing assistance with activities of daily living (ADLs) will conserve the client's energy for activities the client values. Clients who take longer than 1 hour to complete a meal may require assistance (Evans, 1992).

7. Evaluate client's laboratory studies (serum albumin, serum total protein, serum ferritin, transferrin, hemoglobin, hematocrit, vitamins, and minerals).
An abnormal value in a single diagnostic study may have many possible causes, but serum albumin less than 3.2 g/dl was shown to be highly predictive of mortality in hospitals, and serum cholesterol of less than 156 mg/dl was the best predictor of mortality in nursing homes (Morley, 1997).

8. Maintain a high index of suspicion of malnutrition as a contributing factor in infections.
Impaired immunity is a critical adjunct factor in malnutrition-associated infections in all age groups in all populations of the world (Chandra, 1997).

9. Be alert for food-nutrient-drug interactions.
Individuals at greatest risk are those who are malnourished, consume alcohol, receiving many drugs long term for chronic diseases, or take medications with meals or through a feeding tube (Lutz, Przytulski, 2001). Case reports still appear in medical journals describing scurvy in persons with alcoholism (Garg, Draganescu, Albornoz, 1998).

10. Assess for recent changes in physiological status that may interfere with nutrition.
The consequences of malnutrition can lead to a further decline in the patient's condition that then becomes self-perpetuating if not recognized and treated. Extreme cases of malnutrition can lead to septicemia, organ failure, and death (Arrowsmith, 1997). Diarrhea in patients receiving warfarin has been suggested as possibly causing lower intake and/or malabsorption of vitamin K (Black, 1994; Smith, Aljazairi, Fuller, 1999).

 11. If the client is pregnant, ensure that she is receiving adequate amounts of folic acid by eating a balanced diet and taking prenatal vitamins as ordered.
All women of childbearing potential are urged to consume 400 (g of synthetic folic acid from fortified foods or supplements in addition to food folate from a varied diet (National Academy of Sciences, 1998).

12. Observe client's relationship to food. Attempt to separate physical from psychological causes for eating difficulty.
It may be difficult to tell if the problem is physical or psychological. Refusing to eat may be the only way the client can express some control, and it may also be a symptom of depression (Evans, 1992).

13. Provide companionship at mealtime to encourage nutritional intake.
Mealtime usually is a time for social interaction; often clients will eat more food if other people are present at mealtimes.

14. Consider six small nutrient-dense meals vs. three larger meals daily to reduce the feeling of fullness.
Eating small, frequent meals reduces the sensation of fullness and decreases the stimulus to vomit (Love, Seaton, 1991).

15. Weigh client weekly under same conditions.

16. Monitor food intake; specify proportion of served food that is eaten (25%, 50%); consult with dietitian for actual calorie count.

17. Monitor state of oral cavity (gums, tongue, mucosa, teeth).

18. Provide good oral hygiene before and after meals.
Good oral hygiene enhances appetite; the condition of the oral mucosa is critical to the ability to eat. The oral mucosa must be moist, with adequate saliva production to facilitate and aid in the digestion of food (Evans, 1992).

19. If a client has anorexia and dry mouth from medication side effects, offer sips of fluids throughout the day.
Although artificial salivas are available, more often than not clients preferred water to the more expensive products (Ganley, 1995).

20. Determine relationship of eating and other events to onset of nausea, vomiting, diarrhea, or abdominal pain.

21. Determine time of day when the client's appetite is the greatest. Offer highest calorie meal at that time.
Clients with liver disease often have their largest appetite at breakfast time.

22. Offer small volumes of light liquids as an appetizer before meals.
Small volumes of liquids (up to 240 mL) stimulate the gastrointestinal tract, which enhances peristalsis and motility (Rogers-Seidel, 1991).

23. Administer antiemetics as ordered before meals.
Antiemetics are more effective when given before nausea occurs.

24. Prepare the client for meals. Clear unsightly supplies and excretions. Avoid invasive procedures before meals.
A pleasant environment helps promote intake.

25. If food odors trigger nausea, remove food covers away from client's bedside.
Trapped odors diffuse into air away from client.

26. If vomiting is a problem, discourage consumption of favorite foods.
If favorite foods are consumed and then vomited, the client may later reject them.

27. Work with client to develop a plan for increased activity.
Immobility leads to negative nitrogen balance that fosters anorexia.

28. If client is anemic, offer foods rich in iron and vitamins B12, C, and folic acid.
Heme iron in meat, fish, and poultry is absorbed more readily than nonheme iron in plants. Vitamin C increases the solubility of iron. Vitamin B12 and folic acid are necessary for erythropoiesis.

29. If the client is lactose intolerant (genetically or following diarrhea), suggest cheeses (natural or processed) with less lactose than fluid milk. Encourage client to identify the extent of the intolerance.
When lactose intake is limited to the equivalent of 240 ml of milk or less a day, symptoms are likely to be negligible and the use of lactose-digestive aids unnecessary (Suarez. Savaiano, Levitt, 1995).

30. For the agitated client, offer finger foods (sandwiches, fresh fruit) and fluids that can be ingested while pacing.
If a client cannot be still, food can be consumed while he or she is in motion.

Geriatric

1. Assess for protein-energy malnutrition.
Protein-energy malnutrition in older persons is rarely recognized and even more rarely treated appropriately (Morley, 1997). Clients in institutions are susceptible to protein-calorie malnutrition (PCM) or protein-energy malnutrition when they are unable to feed themselves. When followed for 6 months in a long-care hospital, 84% of patients had an intake below estimated energy expenditure and 30% were below estimated basal metabolic rate (BMR) (Elmstahl et al, 1997). Patients admitted to a geriatric rehabilitation unit had an average of four nutritional problems. The primary nutrition problem was protein-energy malnutrition, which was associated with an increased length of stay (Keller, 1997). Nutritional risk independently increased the likelihood of death in cognitively impaired older adults (Keller, Ostbye, 2000).

2. Interpret laboratory findings cautiously.
Compromised kidney function makes reliance on urine samples for nutrient analyses less reliable in the elderly than in younger persons.

3. Offer high protein supplements based on individual needs and capabilities. Give client a choice of supplements to increase personal control. If client is unwilling to drink a glass of liquid supplement, offer 30 ml per hour in a medication cup and serve it like medicine.
Patients with decreased kidney function may not be able to excrete the waste products from protein metabolism. Often the elderly will take medications when they will not take food. The supplement is then served as a medicine.

4. Offer liquid energy supplements.
Energy supplementation has been shown to produce weight gain and reduce falls in frail elderly living in the community. It also has been shown to decrease mortality in hospitalized older persons and to decrease morbidity and mortality in hip fracture patients. When given liquid preloads 60 minutes before the next meal, older persons consistently ate a greater total energy load (Morley, 1997). Inadequate kilocaloric intake has been correlated with increased mortality in the elderly (Elmstahl et al, 1997; Incalzi et al, 1996).

5. Unless medically contraindicated, permit self-selected seasonings and foods.
Older persons rate flavor as the most important determinant of their food choice. Ability to taste declines in most but not all aging clients. Usually salt receptors are most affected and sweet receptors least affected. Blindfolded older subjects have about one half the ability of younger subjects to recognize blended foods, which predominantly results from a decline in olfactory sense (Morley, 1997). In hospitalized patients permitted their preferred food, ice cream, ad libitum, protein-energy malnutrition was reversed (Winograd, Brown, 1990).

6. Play relaxing dinner music during mealtime.
On a nursing home ward for demented patients, the patients ate more calmly and spent more time with dinner when music was played (Ragneskog et al, 1996). Selections with a slow tempo, at or below the human heart rate, have usually been used to dampen environmental noises that might otherwise startle clients. Fewer incidents of agitated behaviors occurred during the weeks that music was played compared with weeks without music (Denney, 1997).

7. Assess components of bone health: calcium intake, vitamin D status, and regular exercise.
The Adequate Intake (AI) for calcium for adults aged 19 to 50 years is 1000 mg. For those >50 years of age the amount is 1200 mg (National Academy of Sciences, 1998). Milk and milk products are the best animal sources of calcium, followed by sardines, clams, oysters, and salmon. In milk, calcium is combined with lactose, which increases absorption (although only 28% of the available calcium in milk is absorbed). Besides lactose, another advantageous component in milk is the protein the osteoblasts need to rebuild the bone matrix. In sum, milk is such an important source of calcium that it is virtually impossible to obtain adequate dietary calcium without milk or dairy products (Lutz, Przytulski, 2001). In the absence of adequate exposure to sunlight, the AI for vitamin D is set at 5 mg/day for persons 31 to 50 years of age, 10 mg for those 51 to 70 years of age, and 15 mg for persons (71 years of age (National Academy of Sciences, 1998). An 80-year-old person requires almost twice as much time in the sun to produce the same amount of vitamin D as a 20-year-old person does (Ryan, Eleazer, Egbert, 1995). Even among institutionalized elderly, prevalence of vitamin D deficiency showed significant seasonal variation (Liu et al, 1997). The USDA Modified Food Guide Pyramid for People Over 70 Years of Age specifies calcium, vitamin D, and vitamin B12 supplementation (Russell, Rasmussen, Lichtenstein, 1999). Exercise not only increases bone density but also increases muscle mass and improves balance (Nelson et al, 1994).

8. Instruct in wise use of supplements.
Milk-alkali syndrome has occurred in women ingesting 4 to 12 g of calcium carbonate daily (Beall, Scofield, 1995).

9. Consider social factors that may interfere with nutrition (e.g., lack of transportation, inadequate income, lack of social support).
Nutritional deficiencies are seen in at least one third of the elderly in industrialized countries (Chandra, 1997). In most surveys, poverty was found to be the major social cause of food insecurity and weight loss, but friendship networks play an important role in maintaining adequate food intake (Morley, 1997).

10. Assess for psychological factors that impact nutrition. Watch for signs of depression.
In persons with depression, 90% of the elderly lose weight, compared with 60% of younger persons (Morley, 1997).

11. Consider the effects of medications on food intake. Appetite-stimulating drugs may have a role in some cases.
The side effects of drugs are a major cause of weight loss in older persons (Morley, 1997). Compared with a placebo, megestrol acetate improved appetite and promoted weight gain in geriatric patients (Yeh et al, 2000).

12. Provide appropriate food textures for chewing ease. Insert dentures (if needed) before meals. Assess fit of dentures. Refer for dental consultation if needed.
The bony structure of jaws changes over time, requiring adjustment of dentures. The most common feeding difficulties among geriatric rehabilitation clients involved dentures (lack of or ill fitting) and oral infections (Keller, 1997).

NOTE: If client unable to feed self, refer to Nursing Interventions and Rationales for Feeding Self-care deficit.

Multicultural

1. Assess for dietary intake of essential nutrients.
Studies have shown that black women have calcium intakes of (75% of the RDA (Zablah et al, 1999). Hispanics with type II diabetes also often have inadequate protein nutritional status (Castenada, Bermudez, Tucker, 2000). Mexican-American women have a higher prevalence of iron deficiency anemia than non-Hispanic white females (Frith-Terhune et al, 2000). Rural black men had low caloric intakes coupled with high fat intakes but nutrient deficiencies (Vitolins et al, 2000).

2. 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).

3. Discuss with the client those aspects of their diet that will remain unchanged.
Aspects of the client's life that are meaningful and valuable to them should be understood and preserved without change (Leininger, 1996).

4. 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).

5. Validate the client's feelings regarding the impact of current lifestyle, finances, and transportation on ability to obtain 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

1. Help client/family identify area to change that will make the greatest contribution to improved nutrition.
Change is difficult. Multiple changes may be overwhelming.

2. Build on the strengths in the client's/family's food habits. Adapt changes to their current practices.
Accepting the client's/family's preferences shows respect for their culture.

3. Select appropriate teaching aids for the client's/family's background.

4. Implement instructional follow-up to answer client's/family's questions.

5. Suggest community resources as suitable (food sources, counseling, Meals on Wheels, Senior Centers).
Teach client and family how to manage tube feedings or parenteral therapy at home.