Sage NCP Form Project

Patient: xxxxxx xxxxxxxxx

Student Name: Meshal Samadzada Case: Nutrition Assessment

Referred for: Nutrition assessment

NUTRITION ASSESSMENT
Food and Nutrition Related History: Has received revious nutrition education regarding a Anthropometric Measurements Age: )ender Ht: &' %(o M *+, Biomedical ata! Medical Tests " #rocedures 1a2s(#at Al2umin )lucos H2A3C /4N e e 39(+(3: N(A N(A N(A N(A Medical ia$nosis%Rele&ant 'onditions: N(A ro riate diet for !" #M$ H!N$ and h% ercholesterolemia -t: *& .g -t Hx: N(A Creat N(A Na5 N(A 65 N(A Hg2 N(A /M": ++0& Hct N(A MC7 N(A 8ther

#ertinent Medications%Supplements%Her(s: Rami ril$ 1i itor$ 7enlafaxine HCl ;R$ Amlo idine$ As irin$ "nsulin <long=acting 2asal and Humalog>$ 7itamin # su S)in status:

lements$ Metamucil

"ntact

Pressure 4lcer(Non=healing ?ound@ Comments:

#atient%'lient%Family Medical%Health%'AM History: !% e " #ia2etes Mellitus$ H% ercholesterolemia$ H!N Estimated Nutritional Needs Based on 'omparati&e Standards: Calories Protein Fluid 3$&99 .cal(da% &3 g(da% Current #iet 8rder Feeding A2ilit% 8ral Pro2lems None "nde endent Che?ing Pro2lem 1imited Assistance S?allo?ing Pro2lem ;xtensive(!otal Assistance Mouth Pain None of the A2ove No Nutritional #iagnosis at this time Proceed to Nutrition #iagnosis /elo?

3 m1(.cal 3$&99 m1 "nta.e )ood <A *BC> Fair <a rox0 B9C> Poor <DB9C> Minimal E <D+BC>

NUTRITION

IA*NOSIS
; <;tiolog%> h%siological causes reFuiring careful use of modified car2oh%drate as evidenced 2%: S <Signs G S%m toms> :=da% food diar% inconsistent ?ith needs + out o : da%s

P < ro2lem> 1ess than o timal inta.e of t% es of car2oh%drate <fi2er> related to:

INTER+ENTION
Recommended Nutrition Prescri tion: Recommended modification E increase overall fi2er inta.e Food or Nutrient #eliver%: N(A Nutrition Counseling: N(A )oal<s>: "ncrease overall fi2er inta.e Nutrition education: Sources of fi2er Coordination of Care <refer to>: N(A

MONITORIN* " E+A,UATION

"ndicators: Fi2er inta.e Criteria: Consume :H g(da% fi2er