Assessment Nutrition Diagnosis Planning Intervention Scientific Explanation Expected Outcome
Subjective: Excessive trans Short Term Goal The nurse will perform Trans fats are basically After 48 hours of
Client verbalized, fats intake After 48 hours of health education on artificial fats. Common nursing intervention,
“Since it is the related to nursing intervention, problems that may sources of trans fats the goal of the client
start of online frequent the client will be able rise due to excessive includes doughnuts, will be met such as:
classes, I have consumption of to: intake of trans fats. french fries, pastries, a. Limiting of food
been stressed as fast foods as Limit the lard, cookies and high in trans fats
I had a hard time food intake The nurse will educate more. Excessive intake b. Developing a daily
evidenced by
adjusting to it. I of trans fats the client on how to may lead to certain food plan menu and
weight gain of 5
consume my rich foods. develop a diet meal complications such as exercise regime.
kg (11 lbs)
time too much Create a plan that consists of increased risk of
on online class during the last daily food adequate nutrition coronary heart After a month, the
and sometimes, three weeks plan menu and help in making an diseases, cancer, client is expected to
have no time to and patient and exercise exercise regime. diabetes, liver toxicity, lose at least 5 kg and
shop for our report of regime. and obesity. will be back to
groceries and consuming milk The nurse will monitor The desirable body normal body index.
cook our food. tea, pizza, Long Term Goal the weight and the weight of the client
We just order burger, and After a month of BMI of the client every should be 120 lbs. but
fast foods and buffalo wings meal planning and week to see the it turns out to be
dishes that are three times a having proper progress of the 145.2 lbs. for eating
available online.” week. exercise regime, the actions. too much trans fats
The client reports client will lose at rich foods. Exercise
consuming milk least 5 kg and will be and proper meal
tea, pizza, burger, back to her normal planning of food that
and buffalo wings body mass index. would not exceed to
three times a the will help promote
week during this loss of adipose tissue
time of rather than lean
pandemic. tissue.
Asia’s FIRST IiP – Gold
Recognition for Proficiency in Quality Accredited University Granted INSTITUTIONAL ACCREDITATION Status Granted AUTONOMOUS Status
Management in 2015
Body Mass Index is
Objective: used as an indicator of
Client readily body fatness. It is a
cooperates to the person’s weight in
interview kilograms divided by
BMI = 27.5 the square of height in
(overweight) meters. Less than 18.5
Age = 40 years indicates underweight
old while 18.5 – 24.9
Height: 5’2 ft indicates normal. 25 –
Weight: 66 kg 29.9 tells that you are
( 145.5 Lbs.) overweight and 30 –
Desirable Body above is obese.
Weight (Ador
Dionisio;s
Method) = 120
Lbs.
Nutrition Care Plan: Dietary History
Asia’s FIRST IiP – Gold
Recognition for Proficiency in Quality Accredited University Granted INSTITUTIONAL ACCREDITATION Status Granted AUTONOMOUS Status
Management in 2015
NUTRITION ASSESSMENT
Name: J. D.
Age: 40 years old
Weight: 66 kg
Height: 5’2 ft
BMI: 27.5 / Overweight
1. Economics
a. Income: Php 23, 600.00
b. Amount of money for food each week: Php 1,500.00
Some food source can be found in our backyard like sweet potato, okra, and eggplants.
2. Physical Activity
a. Occupation: Teacher
b. Exercise: 30 minutes jogging four times a week
c. Sleep-hours/day: 6-8 hours a day
3. Ethnic and Cultural Background:
a. Influence on eating habits: I am a Fullblood Filipino and a Roman Catholic so there are no restrictions when it comes to food variety consumption.
b. Religion: Roman Catholic
c. Education: Master’s Degree holder
4. Home Life and Meal Patterns
a. Number of household members: five
b. Person who does shopping: J. D.
c. Person who does cooking and relationship with this person: L. G. (second oldest child) and also me.
d. Food Storage and cooking facilities: We have refrigerator for food storage and have oven for reheating food.
e. Type of housing: Concrete
f. Ability to shop and Prepare food: We have a budget for food shopping adequate for all the family members. Me, including my second oldest child know how to cook
variety of dishes.
5. Appetite
a. Good, poor, any changes: Since it is the start of online classes, I have been stressed as I had a hard time adjusting to it. I consume my time too much on online class and
sometimes, have no time to shop for our groceries. We just order fast foods and dishes that are available online. We had milk tea, pizza, burger, and buffalo wings. We
even had those food three times a week.
b. Factors that affect appetite: Stress due to work
c. Taste and smell perception: Nothing changed in my taste and smell perception
6. Allergies, Intolerances, and Food Avoidances
a. Foods avoided and reason: I cannot eat crustaceans as I am allergic to it
b. Length of time of avoidance: I have been avoiding it for many years now. From when I knew that I was allergic to it. I can’t remember the exact time.
7. Dental and Oral Health
a. Problems with eating: None, I have no dental problems that can affect my eating
b. Foods that cannot be eaten: None
Asia’s FIRST IiP – Gold
Recognition for Proficiency in Quality Accredited University Granted INSTITUTIONAL ACCREDITATION Status Granted AUTONOMOUS Status
Management in 2015
c. Problems with swallowing, salivation, and food sticking: None
8. Gastrointestinal Concerns
a. Problems with heartburn, bloating, gas, diarrhea, constipation, and distention: None
b. Frequency of problems: None
c. Home remedies: None
d. Antacid, laxative, and other drugs used: None
9. Chronic Diseases
a. Treatment: None
b. Length of time: None
c. Dietary modification: None
10. Medication
a. Vitamin and/ Mineral Supplements: MX3 capsule, Fern-C
b. Medications: None
Asia’s FIRST IiP – Gold
Recognition for Proficiency in Quality Accredited University Granted INSTITUTIONAL ACCREDITATION Status Granted AUTONOMOUS Status
Management in 2015
