Worksheet 10

Assessing Nutritional Status

Case Study

Read the following case study. Then, work through the steps of analyzing the case study data.

1. First, identify the abnormal data and strengths in subjective and objective findings,
2. Assemble cue clusters,
3. Draw inferences,
4. Make possible nursing diagnoses,
5. Identify defining characteristics,
6. Confirm or rule out the diagnoses, and
7. Document your conclusions.

Use the table below to collect subjective and objective date provided to guide you. Propose nursing
diagnoses that are specific to the client in the case study. Identify collaborative problems, if any, for this
client. Finally identify data, if any, which point toward a medical problem requiring a referral.

Case Study

Gina R. is a 43-year-old married woman, who has been newly diagnosed with diabetes mellitus.
She is 157.48 cm (5 ft 2 in) tall, weighs 107.04 kg (236 lb), and has elevated blood glucose levels,
cholesterol, and triglyceride levels. Gina has a college education and two teenage children, one of whom
is away at college. Her husband is on permanent disability resulting from alcohol-induced cirrhosis. Gina
works with an enrichment program for parents of preschoolers. Because she works in a rural area, she
spends a large amount of time driving between client home visits. When interviewed, Gina states that 3
years ago she was diagnosed with a brain tumor but was successfully treated with surgery, radiation,
and chemotherapy. She remains on a maintenance dose of prednisone, which she reports stimulates her
appetite and has caused her-to develop diabetes. Gina takes metformin (Glucophage) to reduce her
blood sugar. She correctly states that this medication can also suppress appetite and promote weight
loss. When questioned about snacks, she reports that she ate half a box of cookies last evening, but
clarified this by stating that they were low-fat cookies. Further interviewing revealed that Gina knows
she must lose weight but states it is difficult because she spends much of her day traveling, has little, if
any, time to exercise, and works long hours, so she and her husband eat out frequently. She denies
smoking or drinking. Gina reports few social contacts due to her husband's illness. She appears very
devoted to her children and her client families that she serves. During the interview, she further states
that food was her only pleasure and now that too has been taken away due to dietary restrictions.
Though often smiling during the interview, Gina shares that life would have been simpler if her husband
had died last summer when he was so critically ill.
Note: Please secure consent before starting the interview to actual client….
NURSING INTERVIEW GUIDE TO COLLECT SUBJECTIVE DATA
QUESTIONS FINDINGS
Biographical Data
Name (use Code Name or Alyas) Gina R.

Gender Female

Address, Phone Number NA

Date and Place of Birth NA

Nationality or Ethnicity NA

Marital Status Married

Religious or Spiritual Practices NA

Primary and Secondary Languages spoken, written, English

and read; Birth Language
Educational Level College graduate

Occupation and Working Status Has an enrichment program for parents of

preschoolers.
Who lives with the client? Identify significant others Two teenage children and a husband.
Caregivers and support people for the client NA

Questions Findings
1. Appetite changes? The patient reports stimulates her appetite.
2. Weight changes in last 6 months? The patient gained weight for the last 6 months.
3. Problems with indigestion, heartburn, bloating, gas? The patient does not experience any indigestion,
heartburn, bloating and gas.
4. Constipation or diarrhea? NA
Past History
1. Food allergies? NA
2. Conditions/diseases affecting intake or absorption? Has elevated blood glucose levels, cholesterol, and
triglyceride levels and been newly diagnosed with
diabetes mellitus.
The patient also states that 3 years ago she was
diagnosed with a brain tumor.
3. Frequency of dieting? The patient states that it is difficult because she
spends much of her day traveling, has little, if any,
time to exercise, and works long hours.
Family History
1. Chronic diseases? NA

2. Weight issues? NA
Lifestyle and Health Practices
1. Average daily food and beverage intake? Patient did not mention the average of her daily food
intake.
2. Type of beverages consumed?
3. Dine alone or with others?
4. Number of meals and snacks per day?
5. Food preferences?
6. Frequency of eating out?
7. Long work hours?
8. Sufficient income for food?
Physical Assessments
1. Gather equipment (balance beam scale with height
attachment, metric measuring tape, marking pencil,
and skinfold calipers).
2. Measure height.
3. Measure weight (1 kg = 2.205 lb).
4. Determine BODY MASS INDEX (BMI = weight in
kilograms/height in meters squared.
5. Measure waist circumference and compare findings.
6. Measure MID-ARM CIRCUMFERENCE (MAC) and
compare findings.
7. Measure TRICEPS SKINFOLD THICKNESS (TSF) and
compare.
8. Calculate MID-ARM MUSCLE CIRCUMFERENCE
(MAMC), MAMC (cm) = MAC (cm) — (0.314 x TSF).
Analysis of Data
1. Formulate nursing diagnoses (wellness, risk, actual).
Did not mention any beverages consumed.
The patient, along with her two teenage children and
her husband eat out frequently.
Did not mention any number of meals and snacks.
The patient mentions that she ate half a box of cookies
last evening, but clarifies this by stating that they were
low-fat cookies.
Did not mention.
Regularly
The patient states that she spends a large amount of
time driving and work long hours.
NA
Findings
Available equipment gathered: metric measuring tape,
marking pencil and balance beam scale with height
attachment.
Patient’s height is 157.48 cm (5 ft 2 inches tall)
Patient’s weight is (107.04 kg = 236 lb)
Patient’s BMI is 43.16, which is considered obese.
Patient’s waist circumference is 40 inches, which
results to abnormal findings.
Patient’s MAC is 28 cm which indicate obesity.
Patient’s TSF is 18 mm which results to obesity.
Patient’s MAMC is 22.3 cm.
Biological Data
 Patient Gina is eating too much food and does
not exercise because of her work that’s why she
was diagnosed with diabetes mellitus.
Wellness Diagnosis
 Nutrition: Readiness for Enhanced Healthy
Lifestyle Engaging Proper Exercise and Proper
food Preparation.
 Health: Readiness for Enhanced Healthy
Management r/t statement of willingness to
learn to do own blood sugar measurements at
home.
 Risk for Elevated Blood Glucose Level r/t deficient
knowledge and lack of adherence to diabetes
management.
Risk Diagnosis
 Risk for obesity related to increasing sedentary
lifestyle and decreasing metabolic demands.
 Risk for coronary heart disease
 Risk for metabolic imbalance syndrome due to

2. Formulate collaborative problems
diabetes melitus
Potential complication of obesity due to improper
lifestyle and lack of nutritional diet can lead to severe
heart disease.
The patient needs an immediate referral to her
physician to manage and treat her diabetes.