Nursing Diagnoses

What exactly is a "nursing diagnosis"? Isn't the doctor the one who diagnoses people? Well, yes. The term "nursing diagnosis" can be a little misleading, and indeed, was very confusing to me when I first started nursing school. A nursing diagnosis is not the same thing as a medical diagnosis - it is not the formal labelling of a patient's condition. That's a physician's job - to assess the patient and figure out what the problem is. The nurse's job is to assess the patient and figure out what practical problems they may face. For example, if a patient has a history of dizziness and is taking a medication that makes them sleepy, a possible nursing diagnosis would be "at risk for falls". This is not a medical diagnosis, but rather a statement of a problem the patient may face that the nurse can intervene in and work to prevent or relieve. It's basically a way for nurses to critically consider how they will care for their patients, and what interventions should take priority.

A nursing practice guideline found here offers a list of possible nursing diagnoses for an obese patient. Five of these nursing diagnoses are below:

• Imbalanced nutrition: more than body requirements
• Knowledge deficit
• Ineffective Health Maintenance
• Activity intolerance (related to impaired mobility)
• Sedentary Lifestyle

 The chart below further explores the first nursing diagnosis.

Nursing diagnosis: Imbalanced nutrition: more than body requirements
Actual or potential problem	Actual problem. For this hypothetical patient, it has already been demonstrated that they consume more calories than their metabolism requires. A potential problem would be described in a nursing diagnosis as “at risk for _____”
What is the problem related to?	This may be related to several issues which we have already discussed. Imbalanced nutrition may be related to deficient knowledge, cultural habits, and limited access to fresh foods.
Plan and desired outcome	Discuss the patient’s current dietary habits. Educate the patient concerning their body’s metabolic needs, how this relates to losing weight (decreasing calorie intake prompts the body to metabolize fats for energy), and how to use a tool like the MyPlate Food Tracker to assess and maintain a balanced diet. Desired outcome is gradual, consistent loss of weight (about 1-2 pounds per week) through a balanced and calorie-limited diet.
Nursing intervention	Provide the education and conversation discussed above, as well as encouragement and continued support during this difficult lifestyle change. Promote enrollment in a cooking class to increase patient’s confidence in preparing healthy meals. Offer information on any local weight loss support groups, particularly ones focusing on proper nutrition.

 

 

 

Nursing Interventions

Nurses have two main roles in treating obesity - education and support. Education might consist of discussions of the potential impact of obesity on health, a safe calorie restricted diet, guidelines for exercise, recommendations for assessing personal hydration, reasonable expectations for a weight loss timeline, and access to resources for additional support or counsel. Support addresses the psychosocial aspects of obesity - patients must feel accepted and not disrespected by their health care providers. As a sort of chronic disease, obesity requires long-term treatment and frequent check-ups. This is not a one-stop visit sort of thing, it requires coordination of care and initiative to maintain contact with patients.

Another important role for nurses is to assess the patient's situation - how they perceive their own weight and health (and how others close to them perceive these things), what their habits are, how they go about their daily life, and if they are impaired in any way by their weight. From this initial assessment, the nurse may be able to begin considering interventions to work with the patient's specific needs - for instance, if a patient recognizes that they binge eat when they are emotionally distressed, the nurse may work to redirect that habit to something less harmful, like calling a friend to talk or doing a calming mental exercise. Or the nurse may discover that a patient doesn't exercise because they have poor vision and fear tripping in their living environment. The nurse may arrange for an optometrist appointment to update glasses prescriptions, and a home visit to assess the safety of the home.

Another significant role of nurses in fighting obesity is preventing it. Every patient that a nurse sees is an opportunity for education in the importance of maintaining overall health through appropriate diet and exercise. Even small steps in the right direction make a big difference.

Of course, none of this is straightforward or easy, otherwise obesity would likely not be the problem that it is. Nurses can participate in research of the issue to promote better understanding of how obesity can be treated and how it may be prevented.

Lewis, S. L. (2014). Obesity. In Harding M. M. (Eds.), Medical-Surgical Nursing - Assess and Management of Clinical Problems. (pp. 906 - 922). St. Louis, Elsevier.

Treatment.

"How can I lose weight?" It seems to be the central question of the last few decades in the much of the Western world. Weight loss theories are everywhere in the media - online, on TV, in the news, on talk shows, in magazines, on library bookshelves, in doctors' offices, at Subway. There's always a new diet or workout or magic pill to try. There are entire TV series dedicated to watching people lose extreme amounts of weight.

 

There are currently three central strategies for combating obesity - weight loss through diet and exercise (lifestyle changes) first and foremost, then medication, then surgery.

 Lifestyle Changes
The National Heart, Lung, and Blood Institute has several recommendations for weight loss through diet and exercise. The recommended healthy rate of weight loss is 1-2 pounds per week.

• Calorie restriction - the number of calories consumed usually needs to be reduced by 500-1000 calories per day. For women, this usually means 1000-1200 calories per day, and for men this usually means 1200-1600 calories per day. An important part of this is portion control - this means eating one piece of toast rather than three.
• Food choices - avoid saturated and trans fats, cholesterol, and excess sodium (these are found in red meats, egg yolks, and processed foods). Choose low fat dairy products (yogurt, milk, and cheese), proteins (lean meats, fish, beans), whole grains (oatmeal, whole grain bread and pasta), and plentiful fresh or frozen fruits and vegetables.
• Physical Activity - to lose weight, it is recommended to exercise at moderate intensity for 300 minutes each week. This exercise can be broken up into 10 minute chunks.
• Change Leisure habits - Reduce the amount of leisure time spent watching TV or on the computer.
• Reward success - set small goals (losing the first ten pounds, eliminating soda, making it to the gym every day for a week) and reward them as you meet them. The reward should not be food, but rather something like a massage, a day trip, or watching a good movie.

One good tool for considering which foods to eat is the USDA "My Plate". It provides some visual perspective on portion size and food groups.

 

ChooseMyPlate.com also has a feature called the SuperTracker, which allows you to enter in all the food you eat in a day and then visually shows your what your diet is in relation to recommended daily food intake. It is based on the standard guideline of 2000 calories per day, but still provides good feedback on whether you're actually eating enough vegetables or not, or if that granola bar is really as healthy as it claims to be. I used the SuperTracker tool to track my food intake for several weeks as a part of a nutrition class, and was surprised to discover that I generally eat too much sodium and not enough whole grains or vegetables.

 

Regardless of the recommendations, it is an immense challenge to lose weight. In order for weight loss to be permanent, there must be a lifestyle change. This is why fad diets fail - they cause intense amounts of weight loss because they are so extreme, but they aren't sustainable in the long run, and so people return to their previous habits and gain the weight back. It is incredibly difficult to change one's lifestyle permanently, especially if your family or culture functions differently than your goal. As I mentioned earlier, food has great cultural and personal significance for many people. I can't eat my mom's molasses cookies without thinking of Christmas and all the happy times associated with it. They are more than just fat and sugar and empty calories - they are a memory that I can participate in every time I eat them. When all the treasured family recipes are heavy in fat and sodium and light on fresh produce, it can feel like treachery to tweak the recipe or try something new. This is why social support is so significant in weight loss, and why obesity is so much larger than just a medical problem - it is a social problem, affected by many interwoven systemic causes.

 

Medications

There are several approved medications available for weight loss. They are usually not prescribed unless the patient has tried lifestyle changes for at least six months without significant weight loss. It's also important to note that these medications are to be used in addition to lifestyle changes. There is no magic pill that will cause maintainable weight loss without changes in nutrition and exercise. One category of weight loss drugs works by blocking the enzyme that allows for fat to be digested, effectively reducing the calories that the body absorbs. Another class of drugs works on receptors in the brain to reduce appetite. All medications have side effects, and must be prescribed and monitored by a doctor.

 

Surgery

The final medical intervention for obesity is surgery. This is reserved for people with extreme obesity (with a BMI of 40 or higher) or moderate obesity with significant health consequences like sleep apnea or diabetes. Reasonable attempts and lifestyle changes like diet and exercise are required before surgery will be considered.

 

 





 The basic function of weight loss surgery is to reduce the size of the stomach or the amount of food the stomach can hold, forcing people to eat less, more frequently, and more slowly. Surgery is usually effective, but can have serious side effects.

Signs and Symptoms

Signs are the effects of disease that a health care worker can note in their assessment (bruising, body shape, blood sugar, lung sounds, heart rate, etc). Symptoms are the patient's experience of a disease, and what they can report to a health care professional (pain, shortness of breath, changes in appetite or mood, difficulties moving, etc).

The central signs of obesity are body shape and BMI, as I discussed in a previous post. The patient's experience is usually not so straightforward. Weight gain is generally very slow, and so people may not realize how much their weight has increased until the day that they can't button their jeans anymore.

This video does a nice job of demonstrating how different things might be if significant weight gain was instant. An extra ten or twenty pounds makes a more noticeably significant impact when people don't have weeks and months to get used to the change.

 

 

Another result of obesity that can have an even more significant impact on people than just having to find bigger clothes is a sense of social stigmatization. Overweight is not the cultural standard of beauty - in fact, underweight often is. With new diets always surfacing, frequent news reports on America's obesity epidemic, and the judging glances of strangers, it is easy to understand how heavy social burden is that obese and overweight people carry. This symptom of obesity must not be overlooked.