Fundamentals of Nursing I

Determine the client's dietary habits and metabolic needs, such as assess the conditions of hair, skin, nails, teeth and mucous membranes.

• 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?
• Assess the client's temperature, pulse, respirations, and height and weight.
• Wellness Diagnoses
• Opportunity 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