NUTRITION
happiness2000
NUTRITIONALASSESSMENTANDINTERVENTIONGUIDE1week6.docxNUTRITIONAL ASSESSMENT AND INTERVENTION GUIDE*
Biophysical Indicators of Nutritional Status
Height (cm): Age: Mid-arm Circumference (in centimeters):
Weight (kg): Calf Circumference (in centimeters):
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Indicator |
Yes |
No |
Description |
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Unplanned weight loss > 10 lbs in 6 months |
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Recent weight gain |
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Change in taste of foods |
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Loss of appetite |
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Increased appetite |
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Food allergies |
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Food intolerance |
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Difficulty chewing |
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Difficulty swallowing |
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Poorly fitted dentures |
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Sore mouth |
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Toothache |
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Choking |
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Dietary restrictions |
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Problems with food preparation ability |
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Fatigue |
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Diarrhea |
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Constipation |
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Nausea |
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Vomiting |
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Dry mouth |
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Belching |
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Heartburn |
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Flatulence |
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Pregnancy |
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Decubiti |
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Recent surgery |
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Crohn’s disease or ulcerative colitis |
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Chronic renal failure |
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Chronic liver disease |
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Cancer |
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Diabetes |
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Hypertension |
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Cardiovascular disease |
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Anemia |
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Hypercholesterolemia |
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*Guide adapted from Clark’s Community Assessment Reference Guide (2008)
Physical Environmental Indicators of Nutritional Status
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Indicator |
Yes |
No |
Description |
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Inadequate facilities for food preparation |
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Inadequate facilities for food storage |
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Lack of access to grocery store |
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Psychological and Sociocultural Indicators of Nutritional Status
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Indicator |
Yes |
No |
Description |
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Depression |
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Mental illness |
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Confusion or disorientation |
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Alzheimer’s disease |
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Social isolation |
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Inadequate food budget |
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Religious food prescriptions |
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Cultural food preferences:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Behavioral Indicator of Nutritional Status
Fluid intake (amount, type, frequency):
Favorite foods:
Foods disliked:
Use of laxatives:
Food preparation practices:
Meal patterns (frequency, timing, amount eaten):
Medications
List all prescribed medications, dose, and frequency taken:
List all over-the-counter vitamins, herbs, supplements taken:
Malnutrition Indicator Score (From MNA Screening Tool):
Nutrition-Related Health Problems Identified:
1.
2.
3.
4.
Nursing Interventions to Improve Nutritional Status and Overall Health
1.
2.
3.
4.
Diet History – Day 1 – List all foods and beverages consumed in a 24 hour period.
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Food and Liquids (include portion size) |
Time |
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Breakfast |
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Lunch |
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Dinner |
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Snacks |
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Diet History – Day 2 – List all foods and beverages consumed in a 24 hour period.
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Food and Liquids (include portion size) |
Time |
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Breakfast |
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Lunch |
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Dinner |
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Snacks |
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Diet History – Day 3 – List all foods and beverages consumed in a 24 hour period.
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Food and Liquids (include portion size) |
Time |
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Breakfast |
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Lunch |
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Dinner |
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Snacks |
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