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Running head: Nutritional Assessment

Nursing 114 Nutritional Assessment

Your name here

Virginia Highlands Community College

April 27, 2011

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Screening

1. Demographic, weight, height:

Client is a ( ) year old female weighs ( ) kg, is and is ( )cm tall.

2. Food Intake:

See 24hr diet recall with calorie count.

3. Weight loss:

Client states ……

4. Mobility:
Gait is ( ). Completed a get up and go test, IADL, and falls risk assessment test
see attached forms.

5. Psychological Aspect:
Client is (ex. alert and oriented to person, place, time and event)

6. Neuropsychological: (*not realy sure exactly what they want here*)

Completed a SPMSQ client answered all questions correctly. See attached form.

7. Body Mass: BMI is BMI = (**kg/*m2) = **BMI

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Assessment

1. Living arrangements: Where, how many in household, and brief description. l

2. Medications: (I just copied and pasted from our home visit)

Trade Name Generic Name Amount Frequency

3. Pressure sores: Anything observed or client states.

4. Meals/day: I used the 24hr food recall from our 109NPP. I helped to get all the
protein, carbs, and fat break down

5. Protein consumption:

**g / day

6. Fruits/vegetables: What and how much the client eats.

7. Fluid intake: What and how much the client drinks.

8. Mode of feeding: Does the client feed his or her self?

9. Self view of nutritional status: How the client views their nutritional health.

10. Self view of health: How client views physical health

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11. Mid-arm circumference:

** inches left arm. (**”x 2.5cm) = **cm

12. Calf circumference:

** inches left leg (16”x 2.5cm) = **cm

Summary:

Clients score on the Nestle Mini Nutritional Assessment was ** and considered

(whatever the malnutrition indicator score was). Client has *******appetite and is or is

not aware they need …………. He or she eats ********* foods and state any problems

with dentures, swallowing, or chewing.

Currently, he or she is (Nursing diagnosis) at risk for ********** related to

***********. To help, the client was provided educational information on the

importance of ***********. As a result he or she is *******(what you did to improve

the problem. Example: use denture adhesive to keep dentures in place or see a dentists

for damaged teeth.

1. Do the client’s medications interfere with their food intake?

Client states “*****”

2. Does the client have difficulty preparing or obtaining their meals?

Client states “****”

3. Does the client’s mental status interfere with his/her oral intake?

Client states “****”

4. Is the client’s diet unbalanced? If so, explain.

Used 24 diet recall from NPP just state any unbalanced info.

5. Does the client have reported skin lesions?

Client states “****”

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6. Develop 4 interventions to improve nutritional status with

rationales.

1. Educated client to ******* Be sure to pull your rationales from one of our nursing
books. (Ex. Fundementals of Nursing pg. **) Nutrition chapter was very helpful

2. Educated Client to ********

3. Educated Client to ********

4. Educated Client to ********

References

Interview of **

My Fitnesspal. (2009). Retrieved from http://www.myfitnesspal.com

Spratto, George., Woods, Adrienne., (2010). Delmar’s Nurse’s Drug Handbook. 2010
Edition.

Wilkinson, Judith., Lueven, Karen., (2007). Fundamentals of Nursing. Theory, Concepts

and Applications. Volume 1