nutrition teaching plan
Nursing Assessment Form
Medical Diagnosis: N/A
Client Perception of Health Needs: Client believes herself to be healthy, however admits to unhealthy dietary practices and an over use of caffeine. Has been feeling that pressures of daily activities are building up.
Client Goals for Health: Client wants to regain a sense of control over daily stressors and improve her overall wellness. Client would like to receive information on ways to improve diet and would like to incorporate physical activity into her lifestyle.
Allergies
(food, medication, environmental)
NKA
Medications
No medications, Vitamins C & D supplements (200mg each daily)
Dietary considerations
Does not eat beef or pork
Vital Signs
T
37.2 C
P
84 BPM
R
14/min
BP
110/75mmHg
O2 sats
98%
Pain rating
N/A
HEALTH ASSESSMENT DATA
Physiological Variable
General Appearance/Mental State
Client is dressed appropriately however grooming is slightly neglected. Clients hair is uncombed and client appears sluggish and fatigued
Cardiovascular System
N/A
Respiratory System
N/A
Gastrointestinal System
N/A
Urinary System
N/A
Sensory Systems
N/A
Nervous System
N/A
Integumentary System
N/A
Musculoskeletal System
N/A
Reproductive System
N/A
Endocrine System
N/A
Spiritual Variable (Environment)
Client is of Hindu beliefs and recognizes god as Shiva. States that she does not practice on any certain day or time but is rather “flexible” in her faith. Client does not consume beef or pork as they are sacred animals.
Developmental Variable (Environment)
Clients appears to have progress through all common developmental stages (behavioural, physical, psychosocial and cognitive) . She presents herself as a very independent, motivated young adult. Expressed no concern in any of these areas.
Sociological Variable (Environment)
Clients claims to be very social and has many friends and a boyfriend. All family lives nearby other than grandparents who
Medical Diagnosis: N/A
Client Perception of Health Needs: Client believes herself to be healthy, however admits to unhealthy dietary practices and an over use of caffeine. Has been feeling that pressures of daily activities are building up.
Client Goals for Health: Client wants to regain a sense of control over daily stressors and improve her overall wellness. Client would like to receive information on ways to improve diet and would like to incorporate physical activity into her lifestyle.
Allergies
(food, medication, environmental)
NKA
Medications
No medications, Vitamins C & D supplements (200mg each daily)
Dietary considerations
Does not eat beef or pork
Vital Signs
T
37.2 C
P
84 BPM
R
14/min
BP
110/75mmHg
O2 sats
98%
Pain rating
N/A
HEALTH ASSESSMENT DATA
Physiological Variable
General Appearance/Mental State
Client is dressed appropriately however grooming is slightly neglected. Clients hair is uncombed and client appears sluggish and fatigued
Cardiovascular System
N/A
Respiratory System
N/A
Gastrointestinal System
N/A
Urinary System
N/A
Sensory Systems
N/A
Nervous System
N/A
Integumentary System
N/A
Musculoskeletal System
N/A
Reproductive System
N/A
Endocrine System
N/A
Spiritual Variable (Environment)
Client is of Hindu beliefs and recognizes god as Shiva. States that she does not practice on any certain day or time but is rather “flexible” in her faith. Client does not consume beef or pork as they are sacred animals.
Developmental Variable (Environment)
Clients appears to have progress through all common developmental stages (behavioural, physical, psychosocial and cognitive) . She presents herself as a very independent, motivated young adult. Expressed no concern in any of these areas.
Sociological Variable (Environment)
Clients claims to be very social and has many friends and a boyfriend. All family lives nearby other than grandparents who