NUTRITIONAL

ASSESSMENT

SUBMITTED TO SUBMITTED BY
Madam Aparna Nandi Madhumita bera
Reader M.Sc. Nursing 1st year
West Bengal Govt. College of Nursing West Bengal Govt. College of Nursing
NUTRITIONAL ASSESSMENT OF CHILDREN
Date and time of assessment –13/11/2022
Place of assessment –Alex Ward, SSKM Hospital
IDENTIFICATION DATA
Baby’s name –Trishna Santra
Age: 2 years 5 months
Name of Father: Tapan Santra

Name of Mother: Tanima Santra

Address – 5, Elgin Road, Sreepally, Bhowanipore, Kol-20
Registration no - 2201919831
Sex - Female
Under Doctor –Dr S. Dutta
Bed no – 36
Date of Admission; 10/11/2022
Birth weight –2750gm (according to mothers history)
Diagnosis – Pneumonia with Respiratory Distress
A. CHIEF COMPLAINT
The child is admitted with complain of difficulty in breathing, cough and cold, loss of apetite.

B. HISTORY OF PRESENT ILLNESS

At present respiratory distress is reduced but cough and cold is present.
C. HISTORY OF PAST ILLNESS

The baby has no any other specific childhood diasease.

D. FAMILY HISTORY

The child belongs to a nuclear family. The child is single child.

Parents of the child has no significant problem.
E. BIRTH HISTORY
• Antenatal History-According to mother history there is no history of hyperemesis
graviderum, eclampsia, preeclampsia, placenta previa or any other specific pregnancy
related complication.
• Natal History- Normal vaginal delivery done on 05/06/2020.
 • Postnatal History- The baby cried immediately after birth and no other specific
abnormality was present on that time.

F. DIETARY HISTORY
Exclusive breast feeding is given upto six month. Weaning is started at 6 months of age. The
baby takes usually homemade regular diet but now the baby has anorexia. The baby use to take
adequate number of cereals, pulses, vegetables, fruits.

Last 24hours dietary recall

MEAL TIME MENU Taken by child Requirements Remarks
by ICMR
nutrition expert
BREAKFAST 8AM Roti(2 pices), Carbohydrate-30gm Carbohydrate- The child took
Milk100ml with Calcium-10g 150gm total1000kcal.
sugar 1 tea spoon Pulses-40gm There is
LUNCH 1PM Rice (1 Carbohydrate-50gm Green leafy deficient
bowl),dal(1boul), Pulses-10gm vegetables-50gm intake of
sabji(1 catory) , Protein-30gm Milk-300ml calorie as per
fish(70gm) Fats and oil-10gm Fats and oil- standard.
Apple-1/4th of one Vegetables-20gm 20gm
piece Meat, fish, egg-
EVENING 6PM Milk with Calcium-10gm 30gm
SNAKES Horlicks(100ml) Carbodydrate-10gm Total calorie
Pulses-5gm requirement-
DINNER 9PM Rice(1/2bowl), Carbohydtare-30gm 1200kcal/day
dal (1boul), sabji Pulses-10gm
(1 bowl) Vegetables-15gm
Fats and oil-10gm

G. IMMUNIZATION HISTORY

Fully immunized up-to the age.

H. BASIC PHYSIOLOGICAL DATA
Vital Signs Normal value Child’s value Inference

Temperature 97.9oF-99OF 98.4OF normal

Pulse (80-130)bts./min 110bts./min normal

Respiration (25-30) brs./min 22brs./min normal

j. DENTITION
Upper central incisor, upper lateral incisor, upper canine, upper first molar, upper second molar,
lower second molar, lower first molar, lower canine, lower lateral incisor teeth are erupted.
K. FONTANELS
Both the fontanels are closed.
ANTHROPOMETRIC MEASUREMENTS

1. Lenght-82cm
2. Weight-11kg
3. Circumference
▪ Head circumference-43cm
▪ Mid upper arm circumference-14 cm

Nutritional assessment of child according to IAP

The child is nutritional status is normal.
BIOCHMEICAL MEASUREMENT
1. Blood examination-Anaemia is not present.
2. Stool Examination-Examination not done
3. Urine examination-In urine examination sugar and albumin is not present in urine.
4. Analysis of hair, nails & skin-Examination not done

CLINICAL EXAMINATION
BODY AREA SIGN OF GOOD SIGN OF POOR FINDINGS REMARKS
NUTRITION NUTRITION
General Alert, responsive Listless, apathetic, Alert, Normal
appearance cachectic responsive
Posture Erect arms and leg Sagging shoulder, Erect arms Normal
straight sunken chess, and leg
humpedback straight
Muscle Well developed, firm, Flaccid, poor tone, Well Normal
good tone, some fat underdeveloped, tender, developed,
under skin wasted appearance not firm, good
walk properly tone, some fat
under skin
Nervous Good attention span, not Inattentive, irritable, Good Normal
control irritable or restless, confused, burning and attention span,
 normal reflex, tingling of hand and feet, not irritable or
psychologic stability loss of position and restless,
vibratory sinewiness and normal reflex,
tenderness of muscle psychologic
stable
Gastrointestinal Good appetite and Anorexia, indigestion, Good appetite Normal
function digestion, normal constipation and diarrhea, and digestion,
regular elimination, no liver and spleen normal
palpable organ or enlargement regular
masses. elimination,
no palpable
organ or
masses.
Cardiovascular Normal heart rate and Tachycardia, Heart rate Normal
function rhythm, no murmurs, abnormal rhythm 108bts/min
General Endurance, energetic, Easily fatigue, no energy, Energetic and Normal
activity sleep well, vigorous falls sleep easily, looks sleep well
tired and apathetic
Skin Smooth, slightly moist, Rough, dry, scaly, Smooth, Normal
good color pale, pigmented, irritated, slightly moist,
bruise, petechiae
Hair Smooth, slightly moist, Dull, brittle, dry, thin and Smooth, Normal
good color sparse, depigmented slightly moist,
easily plucked
Face and neck Skin color uniform, Greasy, discolored, scaly, Skin color Normal
smooth, healthy swollen skin dark over uniform,
appearance, not swollen cheek, and under eyes, smooth,
flakiness of skin around healthy
nose and mouth appearance,
Lips Smooth, good color, Dry scaly, Smooth, Normal
moist, not chapped or swollen, redness and good color,
swollen swelling(cheilosis) or moist
angular stomatitis
Mouth and oral Reddish pink mucous Swollen and boggy oral Reddish pink Normal
membrane membrane in oral cavity mucous membrane mucous
membrane in
oral cavity
Gums and teeth Good, pink color, Spongy, bleed easily, Good, pink Normal
healthy, red , no inflamed, present dental color, dental
swelling or bleeding, no carries carries present
dental carries.
Tongue Good ,pink color or deep Swelling, scarlet and raw, Good pink Normal
reddish in appearance, magenta color color or deep
not swollen or smooth beefy(glossitis), hyperemic reddish in
surface papillae present and hypertrophic papillae, appearance,
atrophic papillae
eye Bright, clear, shiny, no Eye membranes pale(pale Bright, clear Normal
sores at corner of eyelid conjunctivae),redness of shiny, moist
membranes moist and membrane( conjunctival and healthy,
healthy, pink color, no infection),dryness of pink color, no
prominent blood vessels infection, Bitot's spots, prominent
or mound of tissue on redness and fissuring of blood vessels
sclera, no fatigue circles eyelid corners(angular or mound of
beneath palpebritis),dryness of eye tissu on sclera
membrane( conjunctival
xerosis),dull appearance
of cornea( corneal
xerosis ),soft cornea
(keratomalacia)
Neck No enlargement Thyroid enlarged No Normal
enlargement
Nails Firm, pink poon shaped Firm, feet Firm, pink Normal
(koilonychia),brittle
ridged
Legs, feet No tenderness, Edema, tender calf, tenderness, Child have
weakness, or swelling; tingling, weakness weakness, or arthritis
good color swelling;
present
Skeleton No malformations Bowlegs, knock-knees, No Normal
chest deformity at malformations
diaphragm, beaded ribs,
prominent scapula.
REMARKS
The child is well nourished. No signs of nutritional deficiency is found in clinical examination.
HEALTH TEACHING
Health teaching is given regarding the following things:

▪ Periodically deworming.
▪ Adequate consumption of energy producing diet.
▪ Maintenance of personal hygiene.
▪ Immunization.
▪ Regular health checkup