Posted: September 19th, 2022

NUTRITION

NUTRITIONAL ASSESSMENT AND INTERVENTION GUIDE*

Biophysical Indicators of Nutritional Status

Height (cm): Age: Mid-arm Circumference (in centimeters):

Weight (kg): Calf Circumference (in centimeters):

Indicator

Yes

No

Description

Unplanned weight loss > 10 lbs in 6 months

Recent weight gain

Change in taste of foods

Loss of appetite

Increased appetite

Food allergies

Food intolerance

Difficulty chewing

Difficulty swallowing

Poorly fitted dentures

Sore mouth

Toothache

Choking

Dietary restrictions

Problems with food preparation ability

Fatigue

Diarrhea

Constipation

Nausea

Vomiting

Dry mouth

Belching

Heartburn

Flatulence

Pregnancy

Decubiti

Recent surgery

Crohn’s disease or ulcerative colitis

Chronic renal failure

Chronic liver disease

Cancer

Diabetes

Hypertension

Cardiovascular disease

Anemia

Hypercholesterolemia

*Guide adapted from Clark’s Community Assessment Reference Guide (2008)

Physical Environmental Indicators of Nutritional Status

Indicator

Yes

No

Description

Inadequate facilities for food preparation

Inadequate facilities for food storage

Lack of access to grocery store

Psychological and Sociocultural Indicators of Nutritional Status

Indicator

Yes

No

Description

Depression

Mental illness

Confusion or disorientation

Alzheimer’s disease

Social isolation

Inadequate food budget

Religious food prescriptions

Cultural food preferences:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Behavioral Indicator of Nutritional Status

Fluid intake (amount, type, frequency):

Favorite foods:

Foods disliked:

Use of laxatives:

Food preparation practices:

Meal patterns (frequency, timing, amount eaten):

Medications

List all prescribed medications, dose, and frequency taken:

List all over-the-counter vitamins, herbs, supplements taken:

Malnutrition Indicator Score (From MNA Screening Tool):

Nutrition-Related Health Problems Identified:

1.

2.

3.

4.

Nursing Interventions to Improve Nutritional Status and Overall Health

1.
2.
3.
4.

Diet History – Day 1 – List all foods and beverages consumed in a 24 hour period.

Food and Liquids (include portion size)

Time

Breakfast

Lunch

Dinner

Snacks

Diet History – Day 2 – List all foods and beverages consumed in a 24 hour period.

Food and Liquids (include portion size)

Time

Breakfast

Lunch

Dinner

Snacks

Diet History – Day 3 – List all foods and beverages consumed in a 24 hour period.

Food and Liquids (include portion size)

Time

Breakfast

Lunch

Dinner

Snacks

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