Scribd
Upload
261 views4 pages

Clinical Nutrition Assessment Form

The document provides a comprehensive nutritional assessment for a patient, including details about the patient's family, anthropometric measurements, clinical examination findings, and dietary intake. It outlines various health indicators and clinical impressions related to malnutrition, along with laboratory assessments and dietary recall data. The assessment concludes with a comparison of nutritional intake against normal requirements and a classification of the patient's nutritional status.

Uploaded by

shikhaonline88
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
261 views4 pages

Clinical Nutrition Assessment Form

The document provides a comprehensive nutritional assessment for a patient, including details about the patient's family, anthropometric measurements, clinical examination findings, and dietary intake. It outlines various health indicators and clinical impressions related to malnutrition, along with laboratory assessments and dietary recall data. The assessment concludes with a comparison of nutritional intake against normal requirements and a classification of the patient's nutritional status.

Uploaded by

shikhaonline88
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

NUTRITIONAL ASSESSMENT

1. Name of Patient:-
2. Name of village:-

3. Particulars of parents:
S. No. Name of Age Sex Education Occupation Income
parents
4. No. of living children:
 Name of children :-
 Age (Date of birth) :-
 Sex :-
 Order of live birth :-

5. Anthropometry:

Parameter Normal value patients value


Height (cm)

Weight (kg)

Arm circumference

Chest circumference

Head circumference

6. CLINICAL EXAMINATION
a. General impressions-
 Apathy .
 Pallor .
 Viability
b. Hairs-
 Loss of lusture
 Thinning
 Sparse
 Discoloured
 Easily plucked
 Flag sign
c. Face-
 Moon face
 Naolabialdyssebacca
d. Eyes-
 Pigmentation of conjuctival brown
 Conjuctival xerosis
 Bitot’s spot
 Corneal xerosis & keratomalacia
 Normal / Dryness / Hazy or Opaque
 Corneal opacity photophobia
 Night blindness
 Angular conjunctivitis
 Pale conjunctivitis
e. Lips-
 Angular stomatitis
 Cheilosis
f. Tongue-
 Red & Raw
 Fissured / Geographic
g. Teeth-
 Carries
 Mottled enamel
h. Gums-
 Spongy bleeding
 Specify -
i. Glands-
 Goiter
 Specify -
j. Skin-
 Follicular hyperkeratosis
 Mosaic dermotosis
 Pellagrous dermotosis
 Grazy pavement dermatosis
k. Nails-
 Spooning of nails
l. Subcutaneous tissues-
 Edema
 Marasmus
m. Skeletal system-
 Cranial bossing frontal
 Cranial bossing parietal
 Craniatobes
 Beading of ribs
 Knock – knees / Bow – legs
n. Nervous system-
 Numbness of tingling of extremities
 Burning feet
 Tenderness of calf muscle
 Loss of knee ankle jerks
7. Clinical impression:
 Marasmus -
 Pre-kwashiorkor -
 Kwashiorkor -
 Others

Present condition / Nursing :-

8. laboratory Assessment
 HB-
 Hematocrit-
 Albumin-
 Creatinine-
 Urine-
 Stool-
9. Dietary Intake
 Twenty four hour recall
 Food frequency questionnaire-
 Degree of malnutrition
 Shakir’s tape
 Bangle test
 Modified & WAC stick method
 Triceps skin fold thickness
 Inch tape
[Link] condition

Twenty four hour recall

Food items Item Calories Protein Fat (gm) Iron Calcium Vitamin (gm)
(kcal) (gm) (gm) (gm)
Break fast Chappati 193 5 5.5 3 0.02 128

vegetable 122 0.9 1.4 9 0.02 10.7


Lunch Rice 101 0.7 13.5 27 0.02 5.1
Dhal 148.75 2.8 9 36.6 0.07 16.4

vegetable 122 0.9 1.4 9 0.02 10.7


s

Tea Tea 36 - 0.7 38 0.03 0.8

Biscuit 48 5.2 20.2 1.8 0.04


Dinner Rice 101 0.7 13.5 27 0.02 5.1

Dhal 148.75 2.8 9 36.6 0.07 16.4

Vegetable 122 0.9 1.4 9 0.02 10.7

Milk 118 4.4 18 0.8 0.42 118


Total 1242 21.9 73.6 196 0.33 455

Normal 1800 20 35 – 78 10 1000 400


requirement
Excess / deficit Deficit Excess Normal Normal Normal Excess

Total intake : 2120

Total : 1988.83

Comparison : 2120-1988.83= 131.17

Degree of malnutrition 17/18X100=94%

According to IAP classification she is normal.

Bibliography

You might also like