NUR 350 ~ Nutritional Assessment Exercise

Student ____________________________
A] The Biographical Snapshot

The Biographical Snapshot should be concise in a narrative format which informs about the person’s age, marital status,
gender, occupation or prior occupation, race & ethnic origin, religious identity, general health (chronic and acute medical
conditions) and appearance.

The patient is a 28-year-old African-American female who is engaged and identifies as Christian. Her ethnic
origins are from Western Africa and the Caribbean, she identifies as American. She is taller than average for a
woman with medium length dark brown curly hair and dark brown eyes. She works full-time at a private
school as a first grade teacher. Client reports being diagnosed with an autoimmune disease, multiple sclerosis
which sometimes causes her to put her health needs on the back burner. She also reports having iron deficiency
anemia, as well as being on the line for high blood pressure, high cholesterol and diabetes, where she was pre-
scribed Metformin for being insulin resistant. Other than that client is doing well, follows up with her doctor
and makes a conscious effort drink water and eat 3x a day.

B] Physical

1. Weight ___260____ lbs __118.18__ kg [weight in lbs. ÷ 2.2 converts to kg]

2. Height ____67____ inches __1.70__ meters [ height inches X 2.54/ 100]
3. Body Shape: Android= apple, Gynoid= pear ___Andriod/Apple_______
4. Determine BMI- __40.7____. [weight in kg/height in m2] [Jarvis, p.190]

C] History

Recent Weight Change

1. Overall change in past year? ______ Increase __X___ Decrease _____ none
2. Is your weight change related to? __X___effort _____ without trying _______ other
*Client was able to intentionally loose 15 lbs. by doing the Keto diet for about a month and a half and become
more active by taking daily walks.
3. Percent Usual body weight- ___94.5%______[current weight / usual weight X 100] [Jarvis, p.189]

Gastrointestinal Symptoms (that persisted for > 2 weeks)

1. X__None _____Nausea ____Vomiting ____Diarrhea ____ Constipation
2. Have you experienced a change in appetite? ___Increase ___decreased _X__none
3. Do you have any difficulty with chewing or swallowing? ____No_______________

Other History
1. Stress Level (scale of 0 [no stress] to 10 [extremely high stress] ___8_______
*Client suffers from anxiety and sees a therapist weekly as well as take prescribed medication Cymbalta to
help manage her symptoms.
2. Do you have food intolerances or allergies? ______No____________________
3. Do you have religious or cultural restrictions? _____No____________________

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Student ____________________________

D] Elimination

1. How often do you void most days? _____5x a day ________________________________

2. How often do you have a bowel movement? 1x daily after her morning coffee, sometimes 2x
daily

E] Exercise & Activity Patterns

1. Amount & Type: Sedentary/None

2. Response to exercise: Client has not been very active in past few months, due to moving and
planning her upcoming wedding.

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Student ____________________________
F] Nutrition

1. What is your typical daily fluid intake? __1 Liter of water daily, 1 cup of coffee in the morning
daily, 1 cup of juice daily, 1 glass of wine 2 evenings a week___________
2. Who buys the food? _____Self_or fiancé_______________________________
3. Are your finances adequate for food? ___Yes____________________________
4. Who prepares the food? _____Self____________________________________
5. Who is present at mealtimes? ______Self and her fiancé at dinner___________
6. Where do you eat most of your meals? ___At home, typically on the couch in front of the TV
with her fiancé
7. Record 24-hr Recall-

Wednesday August 4, 2021 12 am - 12 am

Wednesday Breakfast:
- 12 oz peach tea
- 1 tbsp honey
- 1 tsp of lemon juice
- 16 oz vanilla blonde latte (from Starbucks)
- 3 oz baguette
- 1 tsp butter
- 1 oz cheddar cheese
- 8 oz of water

Wednesday Lunch:
- 16 oz peach tea
-1 tbsp of honey
- 2 oz of pretzels
- 8 oz water

Wednesday Dinner:
- 8 oz lemonade izze
- 3 lemon pepper wings (fried)
- 3 garlic chili wings (fried)
- 4 oz of Parmesan truffle fries
- 1 cup of salad with
- 1 tbsp of Paul Newmans olive oil and vinegar dressing
- 1 tbsp of craisins
- 16 oz of water

8. Is this a typical pattern most days? If no, explain. Yes, this was a typical day, the only thing
out of the ordinary was that I didn’t get a chance to eat lunch. I typically don’t eat breakfast
and start my day with coffee, tend to eat my vegetables at dinner time and consume 1 L of wa-
ter daily. I find that if I am having a bad day or feeling very overwhelmed and/or anxious, I
tend to eat out more consuming more fatty foods, e,g, fries, fried foods, at least 2x weekly.

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Student ____________________________

9. Is this a typical pattern most days? Yes, however if I am feeling overwhelmed or had a bad
day I may consume less vegetables and drink less water and eat things such as French fries
and Burgers and have a glass of wine or 2.

G] Evaluation

Diagnosis: patient’s nutritional status: [check one]

Normal __________
At Risk Malnourished __X_________________
* Although client is overweight, obese according to her BMI, she is still at risk for being
malnourished due to her lack of proper nutrients “micronutrient deficiencies”. “Despite
an excess of dietary calorie intake, obese individuals have relatively high rates of
micronutrient deficiencies” (Via). Being anemic is already an indicator of micronutrient
deficiency (Global Nutrition Report).
At Risk Over nourished _________________

EDUCATIONAL RECOMMENDATIONS (based on Nutritional Assessment)

(Include, food, fluid intake, exercise)

Food: Based on clients diet, I can see that she is not eating enough of a variety which means that
she is not getting all the nutrients that she needs. Her diet shows that she is not consuming enough
Vitamin E, Vitamin A, Vitamin C and Vitamin D. She is however consuming more than 2x the recom-
mended amount of animal protein and 2x the amount of recommended grains which happens to be
refined. This in turn is increasing her fat and sugar intake along with all of the snacking that she does
which contributes to putting her at risk for insulin resistance/diabetes, hypertension, cardiovascular
disease, etc. which is something she should be mindful of with a high BMI and lack of physical activ-
ity. To satisfy all of her nutrient requirements, I would recommend that she increase her daily fruit
and vegetable servings, bell peppers, strawberries to supplement for Vitamin C, nuts, asparagus to
supplement for Vitamin E, carrots and cantaloupe to supplement for Vitamin A as well as dairy to sup-
plement for Vitamin D and Calcium (Grodner, 2020, p. 115 - 116),. Also because client is African

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Student ____________________________
American and reports being diagnosed with Multiple Sclerosis which predisposes her to having low
Vitamin D levels, I would strongly suggest she take Vitamin D supplements.
Fluid intake: Client reports drinking on average, 1 liter of water daily, 1 cup of coffee daily, 1 cup of
juice daily and on average 2 glasses of wine weekly in the evening. With the daily recommended ad-
equate intake for water being 2.1 L for women (Grodner, 2020, p. 125), client would have to double
her water intake, especially considering the daily caffeine and weekly alcohol consumption which in-
creases water loss. I would recommend that client also consider adding more fruits and vegetables
to her diet with a high water content such as cucumbers, melons, spinach, tomatoes etc. to help stay
hydrated and satisfy her water requirement to replenish her cells and transport nutrients.

Exercise Level: For the past few months, clients activity level has been sedentary. All physical ac-
tivity that is done happens when she goes to the store and run errands, which is about 1x daily and
for no more than an hour of light walking for 15 mins. Even with getting out of the house and walking
throughout the store, client is still not fulfilling the weekly recommended amount of physical activity
which is 150 minutes of moderate exercise or 75 minutes of vigorous exercise. Client should in-
crease her physical activity by joining a gym and going 3x a week for an hour or signing up for a fit-
ness class such as yoga, zumba or pilates, to incorporate strength training as well as cardio.

Citation:

Grodner, M., Escott-Stump, S., & Dorner, S. (2020). Nutritional foundations and clinical applications:
a nursing approach. St. Louis, MO: Elsevier Mosby. (p. 90, 125, 127).

Global Nutrition Report. (2020). About Malnutrition. Retrieved August 05, 2021, from https://
globalnutritionreport.org/resources/about-malnutrition/

Via, M. (2012, March 15). The malnutrition of obesity: Micronutrient deficiencies that promote
diabetes. Retrieved August 5, 2021, from
https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3313629/

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