CLIENT ASSESSMENT :
A model for carrying out your first client assessment for NURS 1100

 

I. PICK A FRAMEWORK THAT CONSIDERS THE CLIENT AS A WHOLE.

Example : Gordon's Functional Patterns

II. SCREEN CLIENT IN ALL AREAS IDENTIFIED BY THE SELECTED FRAMEWORK

III. COMPILE A LIST OF THE CLIENT'S AREAS OF STRENGTHS AND AREAS OF WEAKNESSES

IV. PRIORITIZE THE PROBLEMS AREAS IN TERMS OF

  1. Immediate threat to life
  2. Current distress to client
  3. Potential harm

V. BEGIN WORK ON THE MOST IMMEDIATE PROBLEM

  1. Make a complete client assessment in the specific problem area. In NURS 1100 the assessment to be carried out is in area of Nutritional Functioning.

 


COMPONENTS TO INCLUDE IN A NUTRITIONAL ASSESSMENT

Methods to include

  1. interview for subjective cues
  2. observation for physical objective cues
  3. client report of intake in the form of a 24 hour diet recall

Interview Topics

  1. Eating patternsapples.jpg (22207 bytes)
  • When
  • Where
  • With who
  1. Eats as a response to
  • Hunger?
  • Social situation?
  • Clock(time to eat)?
  1. Usual servings size
  • Man sized portions?
  • Varies according to situation?
  • Hardly enough for a bird?
  1. Use of food substitutes
  • Ensure, etc.
  • Diet drinks
  • Sugar substitutes
  • Non-foods(pica)
  1. Weight history in the last few years
  2. Any changes in swallowing, taste, or appetite
  • Cause if known
  • Effect of particular foods on appetite
  • Food preferences
  • Food aversions
  1. Cultural and/ or religious customs effecting food intake (include fasting)
  2. Family history of nutritional or metabolic disorders, such as diabetes
  3. Description of own body (body image) as a screening for an eating disorder.
  • Compare client's description with your observation of the client's appearance
  1. Self care behaviors r/t nutrition
  1. Ability to grocery shop including:
  • Mental acuity
  • Physical limitations
  • Ease of transportation to a store
  • money available for food
  1. Ability to prepare food including:
  • Knowledge base
  • Interest in cooking
  • Physical limitations
  • Kitchen facilities
  1. Activity and exercise history over the last year
  2. Food allergies or intolerances or restrictions imposed by doctor or another person
  3. Current medications or over the counter drugs that might effect food intake
  • From doctor
  • Self selected for discomforts/ symptoms
  • Vitamins & minerals
  1. Recreational or habitual use of:smokes.gif (36720 bytes)
  • Tobacco
  • Alcohol
  • Street drugs
  • Prescription drugs
  1. Calorie drain from
  • An infection
  • A chronic illness
  • A trauma
  • Surgery
  • A burn
  • Vomiting
  • Diarrhea
  • Emotional stress
  1. Physical discomforts r/t
  • Eating
  • Digestion
  • Elimination
  1. Most recent measurement know for
  • Height
  • Weight

 

Observed Objective Cues r/t Client's Nutritional Status

  1. (obese/ healthy/ malnourished)
  2. General appearance
  • Facial expression
  1. Relaxed
  2. Stressed
  • Posture
  • Client's environment
  • Energy level
  • Self care
  1. Dress
  2. Neatness
  3. Cleanliness
  1. Make a close examination of
  • Skin
  1. Underlying pink tones
  2. Turgor (rebound stretch)
  3. Texture
  4. Marks/ lesions/ bruises
  • Hair
  • Eyes
  • Lips
  • Nails
  • Tongue
  • Gums

 

24-HOUR DIET RECALL

  1. Help the client to record all the food and fluids ingested in the last 24 hours. Include:
  • The kind of fluids taken with and between meals including water
  • The specific kind of food eaten during or between meals
    [example : potato chips not snack food]
  • The amount of each serving of food and each drink of fluid
    [example: 5 ounces of hamburger, 6 ounces of Pepsi]
  1. Tally the number of servings of foods in each Food Group ingested in the last day.
  2. Use these Food Groups:
  • Fats. Oils, sweets
  • Milk, yogurt, cheese
  • Meat, poultry, fish, dry beans, eggs, nuts
  • Vegetables
  • Fruits
  • Bread, rice, cereal, pasta
  1. Compare the tallied total in each Food Group in the Food Pyramid with the Recommended Amounts
  • Fats. Oils, sweets few
  • Milk, yogurt, cheese 2 or 3
  • Meat, poultry, fish, dry beans, eggs, nuts 2 or 3
  • Vegetables 3 - 5
  • Fruits 2 - 4
  • Bread, rice, cereal, pasta 6 - 11
  1. Discuss with the client how his/ her food and fluid intake compares with the recommended amounts in each Food Group.
  2. With the client explore ways acceptable to the client that his/her eating pattern might be changed to be more healthful.

 

CHL: 7/97 10 nutritional assessment.doc

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