Physical Examination and 24hour Diet Recall

A physical examination is what will provide the objective part of the assessment and is of vital importance to arrive at the correct nursing diagnosis and will be the base for an individualized plan of care. Starting with a general assessment, if her nutritional status is poor, the nurse will observe the client is apathetic and inattentive, skin is dry and scaly (including lips), BMI less than 18.5 (dividing weight in kg by height in m2) (National Heart Lung and Blood Institute, n.d.), sagging posture, poor muscle tone and weakness, rapid and irregular heart rate, dry and dull hair and pale and dry mucous membranes and conjunctivas (Potter, Perry, Stockert, & Hall, 2012).

A diet history is a very valuable subjective tool for assessment and it helps ensure patient centered care by involving the patient in her own care. Since Mrs. Green stated that her daughter works out 3-4 hrs per day, it is very important to make sure that Chelsea is receiving nutrients appropriate for her level of activity, thus her energy needs. The diet history can be used to calculate the client's nutritional intake and compared to Dietary Reference Intake (DRI) to determine adequacy of dietary habits (Potter, Perry, Stockert, & Hall, 2012).

Chelsea, who is an adolescent, has an increase in her metabolic demands asides from her exercise because of the growth period she is going through and it is important to take that into account. To meet the demands of her body, she needs carbohydrates, protein, adequate hydration, iron to prevent anemia, among other nutrients. In general, both tools are highly valuable for an assessment and data clustering to arrive at the appropriate actual or risk-for nursing diagnosis. It also helps define the related factors for a better and more individualized plan of care with the necessary interventions including referrals (e.g., Registered Dietitian, RD).

References:

National Heart Lung and Blood Institute. Calculate your body mass index. (n.d.). Retrieved from http://nhlbisupport.com/bmi/

Potter, P., Perry, A., Stockert, P., & Hall, A. (2012). Fundamentals of nursing. (8th ed., pp. 1002-1003, 1007-1011). St. Louis, MO: Elsevier Mosby.

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