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NURS 112 Clinical
Valerie tidoe
Lexi Hought
2/24/25
NURS 112 Clinical
Discuss the nutritional needs of your resident.
1.
Are they on a therapeutic diet? If so, why?
The resident’s dietary requirements are essential to maintaining his health and avoiding complications. The resident’s BMI is 34.3, and he falls under the obese category, placing him at greater risk for many chronic diseases. A balanced diet and controlled calorie count are required to enhance his body weight control and overall health.
The resident is not currently under any therapeutic diet, but in light of his status of obesity, he could be subjected to a structured diet. A therapeutic diet is commonly prescribed to manage a disease, cause weight reduction, or promote overall health. Obesity also comes along with many diseases, and the resident should, therefore, be subjected to a diet low in added fats, refined sugars, and added calories.
A healthy diet should be based on lean proteins like chicken, fish, legumes, and generous quantities of vegetables and fruits. Whole grains like quinoa and brown rice are substituted with refined carbs. It also means regulating the amounts to avoid overeating
2.
According to the textbook, what are their daily caloric requirements?
Based on general nutrition recommendations, the 34.3 BMI adult should consume approximately 1,800 to 2,200 daily calories to maintain the same weight. However, to attain effective weight loss, the diet in terms of caloric content should be 1,500-1,800 calories per day. The reduced diet shall provide the resident with the necessary nutrition to achieve a healthier body weight
3.
How do they take in nutrients? Do they need assistance? Are they at risk for aspiration?
The residents only need assistance with the setup, and they eat independently. This implies the resident eats independently but possibly needs help preparing the meal or setting up the tray. The resident does not exhibit any signs of aspiration risk, indicating that the resident does not experience trouble swallowing and lacks a history of choking. Nonetheless, monitoring the resident’s status regarding safely consuming food is also essential.
4.
What is the height, weight, and BMI?
Height: 5’4″ (65.0 in)
Weight: 177 lb (89.4 kg)
BMI: 34.3 (Obese category)
5.
What was their average fluid intake? What % did they eat?
Fluid intake: 240 ml (without nutritional supplements)
Food intake: 100 %
Fluid intake is minimal, and the failure to document food intake is worrisome regarding whether the resident receives adequate nutrition. Dehydration and malnutrition can lead to weakness, confusion, and other complications.
6.
Do you think the resident’s nutritional needs are being met? Why or why not? What recommendations do you have?
The resident consumes 100% of the food, meaning they are meeting their dietary intake and fluid intake Even though the resident is consuming enough food, a confirmation should be made that the resident is consuming balanced meals according to their diabetic diet plan.
The resident uses bed rails on both sides, indicating the need for support and safety while the bed is occupied. They require a full-body lift transfer with a wheelchair sling, which also shows impaired mobility. In addition, using a mechanical device for transfers and a motorized wheelchair with a Roho cushion is evidence of mobility deficits that require assistive technology to move and ensure comfort.
The resident is at significant risk for skin breakdown. Impaired mobility, obesity, and the use of assistive devices all heighten the risk of pressure ulcers. Proper skin care and assessment can prevent infection and slow-healing wounds.
The resident’s food intake appears sufficient, as they consume 100% of their meals. result in dizziness, confusion, and kidney problems. It is vital to address this concern to ensure the resident’s health is maintained.
Recommendations:
· Continue to encourage balanced meals as per the diabetic diet.
· Educate the resident on portion control and the importance of hydration.
7.
What education on nutrition would be appropriate for your resident?
Providing nutrition education can empower the resident to make informed choices about their dietary intake. They must understand the importance of consuming various nutrient-dense foods to maintain health. They must also be taught to restrict unhealthy fats and sugars and to increase fiber and protein intake. Meal planning and mindful eating are some of how sustainable dietary habits can be reinforced.
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· Low Fluid Intake (240 ml) – This is less than the recommended daily amount and can lead to dehydration. · Elevated BMI (34.3) – The resident is obese, which increases the risk for diseases like diabetes and heart disease. · High Risk for Skin Breakdown – The resident risks developing pressure ulcers because of their limited mobility. Determine a second concern for your resident. Explain why you chose this. Risk of Dehydration Dehydration is a serious problem that results in complications such as urinary tract infections, kidney problems, and cognitive impairment. Since the resident’s fluid intake is only 240 ml, they may be at risk of dehydration. Dehydration may result in constipation, dry skin, and dizziness, which may also result in a high risk of falls.
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Create a plan related to your second concern. What is the goal? What outcome are you striving for to promote, maintain, or restore your resident’s health? Be specific and discuss outcomes you believe are obtainable during your 4-week clinical experience. It should be something you can do or assist with as a student nurse. Increase the resident’s fluid intake to at least 1,500-2,000 ml daily to improve hydration and prevent dehydration-related complications. The resident should demonstrate improved hydration in four weeks by displaying increased fluid intake, stable vital signs, and no dehydration symptoms. |
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Take action. Determine three nursing interventions that address your second concern and provide a rationale for how the interventions promote your resident’s health. Discuss how they will be implemented. Monitor Fluid Intake and Output Keeping a daily record of fluid intake and urine output will monitor hydration status and show any trends that should be noted. This will include documenting any signs of dehydration, such as dry skin, dizziness, or low urine output. A hydration chart needs to be maintained, and trends seen should prompt adjustment. Continual assessment will allow early intervention if the resident persists with low fluid intake, avoiding dehydration complications. Encourage Regular Fluid Intake The resident should be encouraged to drink water and other hydrating fluids during the day. The reminders to drink fluids can be scheduled hourly, with fluids placed in convenient locations. Providing flavored water, herbal teas, or diluted juices can be more appealing to drink. Educating the resident on hydration benefits, i.e., energy and cognition improvement, will also help promote compliance. Family members or caregivers, if necessary, should also be engaged to reinforce the habit of drinking. Provide Hydrating Foods Feeding foods with high water content, such as watermelon, cucumbers, and soups, can help supplement fluid intake. Incorporating broth-based soups, yogurt, and hydrating fruits into the daily diet can increase fluid intake without requiring the resident to take large amounts of fluid at a single sitting. Popsicles created from natural fruit juice or electrolyte-containing drinks can also be an enjoyable method of increasing hydration. Educating the resident on the value of hydrating foods and making small, sustainable dietary changes can help in long-term hydration control ( ATI 2023) |
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Evaluate the effectiveness of each intervention for your second assessment concern. Did the intervention promote, maintain, or restore health? Encouraging Fluid Intake – This intervention is successful if the resident consumes more fluids and responds by saying they feel better. Monitoring Intake and Output – Keeping correct records will determine if additional steps need to be taken to ensure proper hydration. Providing Hydrating Foods – If the resident consumes more high-water-content foods, their hydration status will improve, reducing the risk of dehydration-related complications. |
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Evaluate the overall progression towards the goal for your second concern for your assigned resident. Was the goal achieved? Why or why not? Would you keep this goal or change it? Evaluation of the progress toward increasing fluid intake is required to determine the effectiveness of the interventions. The goal was partially achieved as the resident showed some improvement in hydration but did not consistently achieve the expected level of 1,500-2,000 ml of fluid intake daily. This was due to occasional refusal to accept fluids and insistence on solid food. Alterations such as offering more fluids through food and providing fluids in smaller, more frequent amounts may be necessary to promote hydration. The goal remains relevant, and the alteration of interventions will allow the resident to maintain enhanced hydration. Continued education and support are needed to maintain progress and prevent dehydration complications. |
References
Sommer, M.S (2023) Davis’s disease & disorders: A nursing therapeutics manual
(7th ed) F.A Davis company. ATI Testing (2023)
