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  • Nutritional Assessment

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    Delphy Varghese
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    This document contains a nutritional assessment form for collecting a patient's demographic information, anthropometric measurements, biochemical test results, clinical signs and symptoms, diet history, and 24-hour dietary recall. It also includes sections to calculate the patient's actual nutrient intake, compare it to recommended allowances, make inferences about any nutritional deficiencies, and provide a recommended menu plan. The form aims to comprehensively evaluate a patient's nutritional status.

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    Nutritional assessment

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    Nutritional assessment

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    This document contains a nutritional assessment form for collecting a patient's demographic information, anthropometric measurements, biochemical test results, clinical signs and symptoms, diet history, and 24-hour dietary recall. It also includes sections to calculate the patient's actual nutrient intake, compare it to recommended allowances, make inferences about any nutritional deficiencies, and provide a recommended menu plan. The form aims to comprehensively evaluate a patient's nutritional status.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    4K views3 pages

    Nutritional Assessment

    Uploaded by

    Delphy Varghese
    This document contains a nutritional assessment form for collecting a patient's demographic information, anthropometric measurements, biochemical test results, clinical signs and symptoms, diet history, and 24-hour dietary recall. It also includes sections to calculate the patient's actual nutrient intake, compare it to recommended allowances, make inferences about any nutritional deficiencies, and provide a recommended menu plan. The form aims to comprehensively evaluate a patient's nutritional status.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 3

    NURSING FOUNDATION

    NUTRITIONAL ASSESSMENT
    DEMOGRAPHIC PERFOMA

     Name:

     Age:

     Gender:

     Address:

     Occupation:

     Life style :

     Ward:

     Bed no / room no:

     Ip no:

     Consultant:

     Diagnosis:

     Functional capacity ( No dysfunction / dysfunctional duration / working sub –

    optimally / ambulatory / bedridden )

     Chief complaints :
    I. Anthropometric measurements
     Height :
     Weight :
     BMI :
     IBW :
     Weight loss ( overall loss in past 6 months )
     Change in past two weeks ( increase / decrease / no change ) :

    II. Biochemical measures


    Sl Investigation with date Patient value Normal value Remark
    no
    1 Hemoglobin
    2 Serum Albumin
    3 Leucocytes
    4 Urea
    5 Creatitine
    6 Serum Ferritin

    III. Clinical
     Present & past Medical history (Chronic diseases present, duration, regular
    medications taking, )
     Surgical History ( surgery undergone , date, complications if any )

    SL Signs & symptoms Present currently If present put a Tick mark ,


    no if not put cross mark in the
    Coolum
    1 Loss of subcutaneous fat
    2 Ascites
    3 Muscle wasting
    4 Dry dull hair
    5 Cheilosis
    6 Glossitis
    7 Oedema
    8 Nausea
    9 Vomiting
    10 Diarrhea
    11 Anorexia
    12 Constipation
    IV. Diet

     Past dietary intake ( no change / duration of change ) :


     Any food allergies :
     Intolerance :
     Preferences :
     Current diet status : ( suboptimal solids /full liquid/hypo caloric
    liquid/starvation/adequate /inadequate )
     24Hr dietary recall

    Sl Time Item Amount Ingredients


    no consumed

     Calculations
     Comparison with recommended dietary allowances

    Sl Nutritional Actual Calculated Remark


    no requirements amount amount
    needed

     INFERENCE
     RECOMMENDED MENU PLAN FOR THE PATIENT TO MEET THE
    DEFICIT

    Sl no Time Item Amount to be Ingredients


    consumed

     CONCLUSION
     REFERENCE

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