Pepito, Alyssa Marie NCM 107 Laboratory

BSN-2B October 26, 2021

Nutritional Assessment
I. Nutritional History
1. How many meals and snacks do you eat each day?
Meals: 2 Snacks: 2
2. How many times a week does you eat the following meals away from home?
Breakfast: NA Lunch: NA Dinner: 3 times a week
3. What types of eating places do you frequently visit? (Check all that apply)
Other: Sidewalk Place
4. On average, how many pieces of fruit or glasses of juice do you eat or drink each day?
Fresh fruit: None Juice (8 oz cup): 2 glass
5. On average, how many servings of vegetables do you eat each day?
1 serving
6. On average, how many times a week does you eat a high-fiber breakfast cereal?
1 Sometimes
7. How many times a week does you eat red meat (beef, lamb, veal) or pork?
Everyday
8. How many times a week do you eat chicken or turkey?
4 times a week
9. How many times a week do you eat fish or shellfish?
Everyday
10. How many hours of television do you watch every day?
2 hours
11. Do you usually snack while watching television?
Yes
12. How many times a week do you eat desserts and sweets?
5 times a week
13. What types of beverages do you usually drink? How many servings of each do you drink a
day?
Water: 12 glass of water
Milk: 1 cup
Juice: 2 glass

II. 24 –Hour recall

1. What time did you go to bed the night before last? What this the usual time?
11:00 pm in the evening
2. What time did you get up yesterday? Was this the usual time?
No, at 6:30 AM
 3. When was the first time you had anything to eat or drink? What did you have and how
much?
A while ago, bread and milk, 1 serving each
4. When did you eat again? Where? What and how much?
A while ago, inside the boarding house, corn beef, and rice, and 1 serving each
5. When did you eat next? What did you eat and how much?
Nothing
6. Did you eat or drink anything else? Anything from 1st to 2nd meal? Anything from 2nd
to 3rd meal? Anything from 3rd meal to bed time?
Yes, “Fish with energy drink” for 1st to 2nd meal and “Fish and corn beef” for 2nd to 3rd meal
7. Was this day’s food intake different from usual? If so, why?
Yes, because when it comes of intake that is your choice of food.
8. Is weekend eating different? If so, why?
Yes, eating in weekend is different because it is more excitement and relaxing.

III. Food Frequency Questionnaire

1. Do you drink milk? If so, how much? What kind? Whole or Skim
Yes, 1 a day skim milk
2. Do you use fat? If so, what kind? How much?
No
3. How many times do you eat meat?
Everyday
Eggs: 3 times a week Cheese: NA Beans: NA
4. Do you eat snack foods? If so, which ones? How often? How much?
Yes, bread, every afternoon, 1 serving
5. What vegetables do you eat? (In each group) How often?
A.
Broccoli: Sometimes Green Pepper: NA Cooked greens: Sometimes

Carrot: 3 times a week Sweet Potato: NA

B.
Tomato: 3 times a week Raw cabbage: NA Asparagus: NA Beets: NA
Cauliflower: NA Cooked Cabbage: Sometimes Celery: NA Peas: NA
Lettuce: NA
6.What fruit do you eat and how often?
A.
Apples or Apple Sauce: Sometimes Apricots: NA Banana: 3 times a week
Berries: NA Peaches: NA Pears: NA Cherries: NA Grape or Grape Juice:
Sometimes Pineapple: Sometimes Plums: NA Raisins: NA
B.
Oranges: Sometimes Orange Juice: 2-3 times a week Grape Fruit: Sometimes
Grape Fruit Juice: -2-3 times a week
7. Bread and Cereal Products
 A. How much bread do you usually eat with each meal? Between Meals?
3 pcs in the morning and 1 in the afternoon
B. Do you eat cereal? (Daily, Weekly)
No
Cooked: NA Dry: NA
C. How often do you eat foods such as macaroni, spaghetti, noodles, and the like?
2 times a week
8. Do you use salt?
Yes
Do you “crave” salts or salty foods?
Yes
9. How many tsp of sugar do you use / day? (1 packet – 1 tsp)
1 tsp
10. Do you drink water? How often during the day? How much each time? How much
would you say you drink each day?
Yes, 12 glasses
11. Do you drink alcohol? How often? How much? Beer, Wine, Others?
Yes occasionally. Others, emperador light with Jamaica or else cold water with ice.

III. Food Diary

Time Place Patient/Client Meal Time Amount of Name and

food served Type of food
6:40 AM House B. E. Breakfast 2 serving Bread and
each milk
12:30 PM At Work B. E. Lunch 2 serving Rice, lumpia,
each and pork
8:30 PM House B. E. Dinner 2 serving Rice, utan,
each and fish

IV. Clinical Examination

Area Observations

1. Hair Thin hair, smooth, straight hair, color

black and there are signs of hair loss
2. Face Round chubby face and no wrinkles
3. Eyes Small eyes
4. Lips Fuller lips and downturned lines at the
corners of the mouth.
 5. Teeth Complete, yellow colored, tooth cavity is
noted.
6. Gums Dark gums
7. Tongue Fat deposition in the back of the tongue
(enlargement of the tongue)
8. Glands
9. Skin Firm, tight, and darkened areas where skin
folds
10. Nails Uniform in color and no discoloration
11. Subcutaneous tissue Increase subcutaneous fat
12. Muscular and skeletal system
13. Internal system A. GIT- No signs of abnormalities
B. NS- No signs of abnormalities
C. CVS- Obese with heart rate <80 bpm

V. Body Mass Index

Height: 5’3 or 160.02 cm
Weight: 80 kg
Formula:
BMI= W (Kg)/ H² (m) or BMI= W (Kg)/ H² (cm) x 10,000
Computation:
BMI= 80 kg / 160.02 cm² x 10,000
BMI= 31.24 kg/m² or 31.2 kg/m²
Interpretation:
Upon basing the BMI result from the BMI chart, the patients BMI result which is 31.2 kg/m² is
higher than 30 which means that the patients’ health condition is Obese.

VI. NCP

CUES/EVIDENCE NURSING OUTCOME NURSING RATIONALE EVALUATION

DIAGNOSIS CRITERIA INTERVENTIONS
SUBJECTIVE: Imbalanced The patient Assess the patient’s Health care staff needs The patient
Nutrition: will verbalize overall condition and to address health will verbalize
“Sige kog kaon More than willingness to for possible conditions that arise willingness to
bisag dili body lose weight. comorbidities acquired from obesity at the lose weight
gutom” requirements secondary to obesity. same time. Some
“Ni dako man (Obese) The patient conditions might The patient
ko pag ayo oy, related to will improve or resolve with will
lack of
naa pay tiyan demonstrate weight loss. demonstrate
knowledge
murag buntis”, necessary Comorbidities that can necessary
about
“Maglisod kog appropriate measures and arise from obesity might measures
ginhawa”, portion size lifestyle be diabetes mellitus, and lifestyle
“Ganahan naku and food modifications hypertension( high modifications
mo niwang” as preparation to lose weight blood pressure), to lose
verbalized by and food deterioration of the weight
the patient. intake that The patient joints, difficulty
exceeds body will be able to breathing, and heart The patient
OBJECTIVE: needs as name and disease. will be able
evidence by prepare to name and
body mass
- Bodyweight is healthy meal Help establish Changing eating habits prepare
index (BMI)>
more than options. behavioral patterns and identifying triggers healthy meal
31.2 kg/m²
healthy for and methods to avoid causing overeating can options.
height overeating help control temptation
and, therefore, weight
- BMI over 30 loss.

Vital signs taken Educate about healthy Knowledge about

as follows: nutrition and proper portion sizes and
portion sizes: calories about different
T: 36.5 °C food will help the
P: 89 bpm patient permanently
R: 20 ppm change diet habits and
BP: 120/90 his or her perception of
healthy eating.

Educate the patient By losing weight

about the benefits of gradually, the patient
losing weight slowly. will be able to keep the
weight off long term.
According to the CDC, it
is healthiest to lose 1 to
2 pounds per week.
Steadily losing weight
emphasizes a
permanent lifestyle
change rather than a
diet.
Recommend the A variety of different
patient engage in exercises keep the
various exercises: patient interested and
motivated to continue
to exercise. Different
workouts provide a
variety that keeps the
patient engaged long
term.

Formulate an eating Although there is no

plan with the patient, basis for recommending
using knowledge of one diet over another, a
individual’s height, good reducing diet
body build, age, should contain foods
gender, and individual from all basic food
patterns of eating, groups with a focus on
energy, and nutrient low-fat intake and
requirements. adequate protein intake
Determine which diets to prevent loss of lean
and strategies have muscle mass. It is
been used, results, helpful to keep the plan
individual frustrations as similar to patient’s
and factors interfering usual eating pattern as
with success. possible. A plan
developed with and
agreed to by the patient
is more likely to be
successful.

Consult with dietitian A variety of factors

to determine caloric require attention and
and nutrient consideration when it
requirements for comes to establishing a
individuals weight loss. meal plan. With a
thorough assessment
and nutritional
knowledge, dietitians
can provide valuable
information by
considering the type of
diet and the amount of
calories needed to lose
weight for a specific
individual. Dietitians will
be able to integrate
ethnic foods into the
meal plan and further
personalize the meal
plan.