EDGEWOOD COLLEGE

Department of Nursing

NRS211:  Introduction to Therapeutic Nursing Interventions

 

NUTRITIONAL ASSESSMENT

 

 

  1. Read Chapters 1 and 13 in Grodner et al. Foundations and Clinical Applications of Nutrition.

 

  1. Complete 24-h food recall with your senior client.

 

  1. Complete “Additional questions to consider” with your senior client.

 

  1. Complete Physical signs. (Omit section on Antropometry and Laboratory Studies).

 

  1. Enter data you obtained from 24-h recall into Mosby’s NutriTrac Analysis disc and print your analysis.

 

  1. Written report to include:
    1. 24 hour food recall
    2. Computer analysis
    3. Summary of ct. strengths and weaknesses re: nutrition.  Include:

-    additional questions

-         physical observations

-         pertinent medical history

    1. discuss 24h food recall and computer analysis you included.  What does this tell you about your ct’s nutritional status?
    2. Give two or three specific recommendations for ct. to improve nutrition.
    3. Self-evaluation: What you did well/could improve.

 

EDGEWOOD COLLEGE

Department of Nursing

NRS211:  Introduction to Therapeutic Nursing Interventions

 

 

24 – Hour Food Recall

 

Initials__________________________  Date: ___________________________

 

Day of Week:_____________________________________________________

 

Directions:  In the space provided, record all food and beverages consumed in the previous 24-hour period.  Include estimated amounts and the time and place when they were eaten.

 

Food and Beverage Consumed

 

Time

Type

Amount

Method of Preparation
(fried baked, broiled, boiled, creamed, toasted…)

Place

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Was this a typical day?  q Yes     q No

 

Do you take a vitamin or mineral supplement (pill)?  q Yes     q No

 

If yes, how often?  ________________________________________

 

What kind?

EDGEWOOD COLLEGE

Department of Nursing

NRS211:  Introduction to Therapeutic Nursing Interventions

 

NUTRITION ASSESSMENT

ADDITIONAL QUESTIONS TO CONSIDER

 

Assess for general factors that may influence nutrition

 

         Socieoeconomic factors

   Psychological factors

         Culture/values

         Religion/religious practices

         Food preference

         Drug and alcohol intake

 

What is the general appearance of the client?

 

Typical eating patterns

 

Does the client have dentures?  If yes, do they fit?  Are they used?

 

Is the client on a special diet?  If yes, are adequate nutrients provided by the diet?

 

Does the client use prepackaged and prepared foods often?

 

Does the client eat fast foods often?

 

Assess diet for adequacy of vitamin and mineral intake.

 

Has there been a recent change in diet?

 

Has there been a recent increase or decrease in caloric intake?

 

If yes, was this intentional?

 

Has there been a recent change in bowel habits, mobility, physical exercise?

 

Have the client describe his/her life style-active, sedentary etc.

 

Does the client have a regular exercise regime?

            Has the client experienced recent physical or emotional stress such as surgery,

            trauma, burns, infection, loss of spouse or job, retirement or other changes that

            may affect nutrition?

 

Does the client take any over the counter medications, especially vitamins or mineral supplements or appetite suppressants?

 

If yes, reason, dose, and beginning date.

 

Does the client use any health foods?  Describe.

 

Review the client’s current medication regime including over the counter preparations.

 

Have the client describe his/her alcohol, tobacco, snuff or caffeine intake.

 

Does the client have any eating disorder?

 

Is there any family history of food allergy, intolerance?

 

Does the client have a history of cardiovascular disease, Chron’s disease, diabetes mellitus, GI tract disorders, sickle-cell anemia, allergies, food inolerance, obesity?

 

EDGEWOOD COLLEGE

Department of Nursing

NRS211:  Introduction to Therapeutic Nursing Interventions

Nutrition Assessment

Physical Signs

 

Body Area

Signs

No

Yes

Comments

 

 

 

 

 

Skin

Dry, flaky scaly

 

 

 

 

Petechiae, ecchymoses

 

 

 

 

Cracks, rash

 

 

 

 

 

 

 

 

Hair

Dull, dry

 

 

 

 

Sparse, shredding

 

 

 

 

 

 

 

 

Eyes

Cloudy, pale

 

 

 

 

Dry

 

 

 

 

Red

 

 

 

 

 

 

 

 

Lips

Swollen, red

 

 

 

 

Cracks as sides

 

 

 

 

 

 

 

 

Tongue

Swollen, red

 

 

 

 

Pale

 

 

 

 

Fissured

 

 

 

 

Magenta

 

 

 

 

 

 

 

 

Gums

Bleeding

 

 

 

 

 

 

 

 

Nails

Brittle, ridged

 

 

 

 

Spoon-shaped

 

 

 

 

Splinter hemorrhages

 

 

 

 

 

 

 

 

Musculoskeletal

Pain in calves, thighs

 

 

 

 

Osteomalacia,  rickets

 

 

 

 

Joint pain

 

 

 

 

Muscle wasting

 

 

 

 

 

 

 

 

Neurologic

Peripheral neuropathy

 

 

 

 

Hyporeflexia

 

 

 

 

Disorientation/irritability

 

 

 

 

 

 

 

 

 

 

 

EDGEWOOD COLLEGE

Department of Nursing

NRS211:  Introduction to Therapeutic Nursing Interventions

 

 

General Appearance:_____________________________________________________________

            Anthropometry

            Triceps, skinfold (TSF)                                      ________________________mm

           

            Mid-upper arm circumference (MAC)                ________________________cm

 

            Mid-upper arm muscle circumference (MAMC) __________________________cm

 

            Mid-arm muscle area (MAMA)                         __________________________cm

 

            Body mass index                                               _________________________

 

            Arm span                                                          _________________________cm

 

            Waist-to-hip ratio                                               _________________________

 

Laboratory Studies

            Serum transferring ________________________________________________mg/dl

 

            Response to skin test antigen ________________________________________mm

 

            Nitrogen balance _________________________________________________

 

            Creatinine height index ____________________________________________%

 

____________________________

 

Ca=calcium; Calor=calories; CHO=carbohydrate; Chol=cholesterol; Fibr=fiber; Prot=protein; Vit B12=Vitamin B12; Vit C=Vitamin C

 

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