MISAMIS UNIVERSITY

Ozamiz City
College of Nursing, Midwifery and Radiologic Technology

l Demographic Data: Patient M, John Michael Dominggo. 19 years of

age. Currently residing at Poblacion San Pablo,
Zamboanga del Sur. A 1st year Nursing student from
Misamis University. He lives in a concrete house
together with his Mother and his father. They’re all
8 family members.

II. Dietary History: He eats 3 times a day normally in breakfast with 2

cups rice, nilat ang baboy, during lunch he eats 2
• How many meals and snacks do you eat in a cups rice, fried fish and pancit canton, in dinner he
24-hour period? eats only nilat ang manok and rice. John doesn’t
• Do you have any food allergies or have allergies and intolerances. He loves to drink
intolerances, and, if so, what are they? coffee but moderately (no caffeine intolerances). He
intakes vitamins such as ascorbic acid and
• What types of vitamin, mineral, herbal, or immunomax which is prescribed by his doctor. He
other supplements do you use and why? doesn’t have acute ill. He occasionally drink
• For clients who are acutely ill, how has illness alcohol “Usahay raman ko mo inom sir, tipsi tipsi
affected your choice or tolerance of food? lang” as verbalized.

• How much alcohol do you consume daily.

III. Clinical Assessment:

Additional Physical Signs and

Symptoms Suggestive of
Malnutrition

• Poor or delayed wound healing or sores “Wala raman koy problema based aning mga
• Thin appearance with lack of subcutaneous symptoms sa malnutrition, sir" as verbalized by the
fat patient.
• Muscle wasting (decreased size and
strength)
• Weakened hand grasp
• Depressed mood
• Abnormal heart rate, heart rhythm, or blood
pressure
• Enlarged liver or spleen
• Loss of balance and coordination

IV Medical-Psychosocial History. He doesn’t have the prescription notes, but

according to his doctor he was prescribed to take
Medications (with doctor’s prescription or over Ascorbic acid and immunomax.
the counter meds)

MISAMIS UNIVERSITY
Ozamiz City
College of Nursing, Midwifery and Radiologic Technology
Psychological factors

• Depression No psychological factor problems.

• Eating disorders
• Psychosis
Social factors
• Illiteracy He is literate on social factors. No difficulty on
language barriers. He admitted that he has limited
knowledge of nutrition and food safety because he
• Language barriers is unconscious on his health. He doesn’t take any
tobacco or recreational drugs. He doesn’t have
• Limited knowledge of nutrition and food problems on both altered intake culture and
safety religion. No difficulty on social support system. He
isn’t introvert or isolated within himself. He can
• Use of tobacco or recreational drugs cook whatever he wants. He doesn’t have income
since he is still a student. No difficulties on
• Limited use or knowledge of community
accessing transportation to obtain foods. He is into
• Altered or impaired intake related to extreme physical activity since he is into people, he
culture loves socializing.

• Altered or impaired intake related to

religion

• Lack of caregiver or social support system

• Social Isolation

• Lack of or inadequate cooking

arrangements

• Limited or low income

• Limited access to transportation to

obtain food

• Advanced age (older than 80 years)

• Lack of or extreme physical activity

V Anthropometric Assessment Data:

• Height He is 5’4 tall. He is 80 kg. BMI is 30.3 which is

considered as Obese. DBW is 56.304 kg, in upper
• Weight range he is considered overweight.
• BMI

• DBW

NUTRITIONAL DIAGNOSIS

• Lists as many as you can identify a nursing diagnoses with nutritional significance based on your
assessment.
Imbalanced nutrition: more than body requirements related to food intake that exceeds body needs.
MISAMIS UNIVERSITY
Ozamiz City
College of Nursing, Midwifery and Radiologic Technology

Name: Augy Elner P. Peteros

BSN 1D