Nursing assessment and Diagnosis for Nutritional-Metabolic Pattern

Nursing History

Assessing the client’s nutritional-metabolic pattern is to determine the client’s dietary habits and metabolic needs. The conditions of hair, skin, nails, teeth and mucous membranes are assessed

Subjective Data

Dietary and Fluid Intake

  • Describe the type and amount of food you eat at breakfast, lunch, and supper on an average day
  • Do-you take any vitamin supplements? Describe.
  • Do you find it difficult to tolerate certain foods? Specify.
  • Do you ever experience nausea and vomiting? Describe.
  • Do you ever experience abdominal pains? Describe.

 

Condition of Skin

  • Describe the condition of your skin.
  • How well and how quickly does your skin heal?
  • Do you have any skin lesions? Describe-
  • Do you have any itching? What do you do for relief?

 

Condition of Hair and Nails

  • Have you had difficulty with scalp itching or sores?
  • Do you use any special hair or scalp care products?
  • Have you noticed any changes in your nails? Color Cracking? Shape? Lines?

 

Metabolism

  • What would you consider to be your “ideal weight”?
  • Have you had any recent weight gains or losses?
  • Do you have any intolerance to heat or cold?
  • Have you noted any changes in your eating or drinking habits? Explain.
  • Have you noticed any voice changes?

 

Objective Data

Assess the client’s temperature, pulse, respirations, and height and weight.

 

Wellness Diagnoses

  • 0pportunity to enhance nutritional metabolic pattern
  • Opportunity to enhance effective breastfeeding
  • Opportunity to enhance skin integrity

 

Risk Diagnoses

  • Risk for Altered Body Temperature
  • Hypothermia
  • Risk for Infection
  • Risk for altered nutrition less than body requirements .
  • Risk for Aspiration

 

Actual Diagnoses

  • Fluid Volume Deficit
  • Fluid Volume Excess
  • Altered Nutrition: Less than body requirements
  • Altered Nutrition: More than body requirements
  • Ineffective Breastfeeding
  • Altered Oral Mucous Membrane
  • Impaired Skin Integrity.

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