REPORT

ON
NUTRITIONAL
ASSESSMENT AND
DIET PLANNING

SUBMITTED TO: SUBMITTED BY:

Praveen Paramesh Mahima chaudhary

Assistant professor BSc Nursing

IINS&R 4th year/7th sem.

CLIENT PROFILE:

Name : Mrs. kamlawati

Age/Sex : 64years/ Female

Classification : geriatric

Education : Nil

Head of the Family : Mr. Rajendar

Address : dipo ,kurshi road,lucknow

PHYSICAL EXAMINATION:

Baseline Data

Height : 158cm

Weight : 51Kg

Temperature : 37o C

Pulse : 74beats/min

Respiration : 22 breaths/ min

Blood Pressure: 110/70 mm Hg (Sitting Position)

General Appearance

Body built : Moderately body built

Appearance : moderately nourished, Clean

Hair and Scalp

Color : white in color

Texture : dry

Scanty : No Scanty

Dandruff : Absent

Lice : Present
 Others : nil

Eyes

Color : eyes dull in color

Cornea : The cornea is black in color

Discharge : discharges present

Wearing Spectacles: No

Others : problem to identify for objects.

Ears

Anatomy : Normal anatomical position

Discharge : cerumen accumulation

Deformed : No deformities

Others : Hearing acuity is slight problem

Nose

Normal : No septal deviation

Discharge : No discharge from the nose

Deformity : Nil

Others : -

Mouth

Normal : Normal

Color : Pink in color

Clear : Clear

Odour : No odor

Coated tongue: Absent

Caries : present
 Lips : Pink in color

Cyanosis : Absent

Bleeding : Absent

Skin

Color : The skin is normal and pale

Growth : There is no growth over

Texture : dry

Intact : Intact

Break/Wound: No wound or break

Dry/moist : Moist

Wrinkle : Absent

Jaundice, anemia: Nil

Ulcer/Scar : Nil

Edematous, rashes: Absent

Neck

General : Normal

Enlargement : No enlargement of thyroid/ parotid

Range of Motion: Normal range of motion

Chest

General : Symmetrical chest wall movement

Dyspnea : There is no dyspnoea

Deformed : No deformity

Respiratory rate: 22 breaths/min

Abdomen

General : Normal

Distention : No abdominal distention

Firm, Soft : Soft and firm to touch

Odour : Nil

Scar : Absence of abdominal sutures

Bowel sounds are heard

Back

Shape : There is lordosis and kyphosis

Deformities : Nil

Pain : present

Extremities

Normal : joint pain in the lower limbs and also numbness Edema :
There is no edema

Dislocation : No dislocation

Clubbing : No clubbing of fingers.

Nail

Clean/ Dirty : Clean

Long/Short : Nails are long

Normal : Normal

Breast

Symmetry : Symmetrical
 Discharges : No discharges,

Scars/Lesions:No scars or lesions

Nipple & areola: Normal and clean

Genitalia

Normal : Normal

Lesions : Absence of lesions

Discharges : No discharges

Elimination

Urine : Passes 4-5 times a day

Stool : Once in a day

NUTRITIONAL ASSESSMENT:

Name : Mrs. Krishnaveni

Age/Sex : 65/F

Classification: geriatric

Education : -

Occupation : -

Income : -

Hair : Normal/Lack of luxture/ Dyspigmented/ Thin built/ Spoarse/

Easily Pluckable/ Flag sign

Face : Diffuse pigmentation/ Nasolabial dysbacea/ Moon face/ Normal

Eye : Conjunctiva/ Normal/ Dry on exposure to half minute/

Dry and wrinkled/ Bitot’s spot/ Brown pigmentation/

 Angular conjunctivitis/ Pale

Cornea : Normal/ Dry

Lips : Normal/ Angular stomatitis/ Cheilosis

Tongue : Pale and flabby/ Red/ Red fissured/ Normal

Teeth : Molted enamel/ Caries/ Alteration/ Normal

Gums : Normal/ Dry and scaly/ Follicular

Skin : Hyperkeratosis/ Petachiae/ Pelagrous dermatitis/ normal

Nails : Koilonychias/ Normal

Odema : Absent/ Independent parts

Glands : Normal/ Parotid or thyroid enlargement

Rachdic changes: Knock – knee/ Bow legs/ Pigeon chest/ Normal

Internal system: Normal/ Hepatomegaly/. Psychomotor changes/ Mental confusion/

Sensory loss/ Muscle wasting/ Loss of ankle and knee jerk/ Calf-tenderness/ Cardiac
enlargement/ Tachycardia

24 HOURS RECALL

Name : Mrs.Kalawati Age/Sex :64 Years/Female

Classification : geriatric
Time Items Amount Energy Protein Fat Calcium Iron Vit.A
K. Calorie (g) (g) (mg) (mg) (mg)
7 AM Tea 100ml 67 3.2 4.1 120 0.2 53
9 AM roti 4 Nos 512 8.2 19.4 56.4 3 22.5
dal 200 ml 101 4.1 3.6 50 2.2 160.0
12 N Rice 250 g 295 6 6 6.9 2.0 2.2
dal 200 ml 101 4.1 4.1 50 2.2 160.0
Buttermilk 25 ml 18.0 0.9 0.9 60 0.1 31
Fish 2 Nos 220.0 17.5 17.5 330 1.6 -
4 PM Tea 100 ml 67 3.2 3.2 120 0.2 53
Sundal 100 gm 192 9.2 9.2 20.1 8.0 4.8
8 PM roti 4 Nos 512 8.2 8.2 56.4 3 22.5
dal 200 ml 101 4.1 4.1 50 2.2 16.0

TOTAL 2186.0 68.7 68.4 874.8 42.7 669.0

COMPARISON OF FOOD TAKEN:

Nutrients Required amount Client actually taken Deficit

Energy 2775 Kilo calories 2186 Kilo calories Deficiency (589 Kilo calories)

Protein 75 g 68.7 g Deficiency( 6.3 g)

Fat 45 g 68.4 g + 23.4 g

Calcium 1000mg 874.8 mg Deficiency ( 125.2 mg)

Iron 30 mg 42.7 mg + 12.7 mg

Vitamin A 950 µg 669 µg Deficiency ( 281 µg)

RECOMMENDED MENU PLAN

Time Items Amount Energy Protein Fat Calcium Iron Vit.A

K. Cal (g) (g) (mg) (mg) (mg)
 7 AM Milk 200 ml 134 6.4 8.2 240 0.4 106
9 AM roti 4 Nos 521 8.2 19.4 56.4 3.0 22.5
dal 100 ml 101 4.1 3.6 50 2.2 160.0
10AM Banana 1 No. 116 1.2 0.3 17 0.36 78
11.30 AM Drumstick 100 ml 26 2.5 0.1 30 0.18 600.0
leave soup
1 PM Rice 250 g 295 6 0.5 6.9 20 2.2
Sambar 200 ml 101 4.1 3.6 50 2.2 160.0
Buttermilk 25 ml 18 0.9 1.4 60 0.1 31
Fish fry 2 nos 220 17.5 0.9 330 1.6 -
4 PM Tea 100 ml 67 3.2 4.1 120 0.2 53
Sundal 200gm 384 18.4 15.6 46.0 18.2 16.0
8 PM roti 4 Nos 512 8.2 19.4 56.4 3 22.5
chutney 100g 269 8.3 1.7 390 22.2 450

TOTAL 2755.0 89.0 78.8 1452.7 73.4 1701