Sage NCP Form Slovack____________ #1: Pediatric Weight Mgmnt_

Patient: Ms. Whitmer

Student Name: _JP Case: _Case

e!erred !or: Weight gain o! more than 1" l#s over the last several $ears

NUTRITION ASSESSMENT
Food and Nutrition Related History: %ood &''etite( consumes a )ide variet$ o! !ood. *o) level o! 'h$sical activit$. & +,-hour recall )as 'rovided: +,-hour recall contained lo) amount o! !ruits and vegeta#les .less than / servings0da$1 as )ell as several servings o! !ull !at milk( and several servings o! sugar-s)eetened #everages such as soda( 2uice and s)eet tea. 3nl$ )hole grain consumed )as 'o'corn. 4cal0da$ 5 67711 kcal0da$ Car#oh$drates: 6 ,8.1 9 total kcal Fat: 67:., 9 total kcal Protein: 61,./ 9 total kcal Anthropometric Measurements &ge: 1" %ender: Female

;t: /8<0 1,,.: cm

Wt: 11/ l#s 0 /+.+ kg Wt ;=: %ained >1" l#s 'er $ear last several $ears

?M@: +,.A .>A/th 'ercentile1

Biomedical ata! Medical Tests " #rocedures *a#s0Bat &l#umin %lucos ;#&1C Cholestero ;B**B*-C C% *B*0;B* e e l C ratio A0++ ,.: g0d* 11+ ,.A 9 1E/ mg0d* 7, 11" 11, mg0d* 7.+7 mg0d* mg0d* mg0d* Medical ia$nosis%Rele&ant 'onditions: 3#structive Slee' &'nea( o#esit$ .?M@ > ./th 'ercentile1 #ertinent Medications%Supplements%Her(s: FlintstoneFs multivitamin taken dail$

MCD

3ther

S)in status:

@ntact

Pressure Glcer0Non-healing )oundH Comments:

#atient%'lient%Family Medical%Health%'AM History: Mother and grandmother 'ossi#l$ have t$'e + dia#etes mellitus Estimated Nutritional Needs Based on 'omparati&e Standards: Calories: +1+" kcal0da$ .GtiliIed the Protein: ".8E K ".A/ g0kg #od$ )eight0da$ Gsing ideal #od$ )eight o! 6A" academ$ o! nutrition and dietetics !ormula l#s0,".A kg !or Cotal Jnerg$ J='enditure .CJJ1 !or over)eight girls age 7-1:1 CJJ 5 7:A K .,1.+ L age M$N1 O P& L .1/." L )eight MkgN + 701.6 height [m]) Protein need: 71.1 K 7:.A g0kg #od$ )eight0da$

Fluid Will use ideal caloric intake o! +1+" kcal0da$ Fluid needs 5 61ml0kg0da$ Fluid Needs 5 6+1+" ml0da$ or +.1 * 0da$

Current Biet 3rder %eneral Biet

Feeding &#ilit$ @nde'endent *imited &ssistance J=tensive0Cotal &ssistance

No Nutritional Biagnosis at this time NUTRITION IA*NOSIS

P .'ro#lem1____ E+cessi&e Ener$y Inta)e ,NI-./01 _______________related to:

3ral Pro#lems Che)ing Pro#lem S)allo)ing Pro#lem Mouth Pain None o! the &#ove Proceed to Nutrition Biagnosis ?elo)

@ntake %ood .> 8/91 Fair .a''ro=. /"91 Poor .P/"91 Minimal K .P+/91

J .Jtiolog$1__ Food and nutrition related )no2led$e de3icit concernin$ ener$y inta)e _____________as evidenced #$:

S .Signs Q S$m'toms1
,. BMI 4 56th percentile ,57th percentile1 ,81 Inta)e o3 3at is 4 09 : total caloric inta)e ,0;/<:1 ,01 Inta)e o3 saturated 3at is 4.9: total caloric inta)e , .6:1 ,<1'alorie inta)e ,=00.. )cal%day1 hi$her than recommended inta)e ,=8.89 )cal%day1

S .Signs Q S$m'toms1

.'ro#lem1__________________________ _ ____________________________related to:

.Jtiolog$1__________________________ __ ________________________as evidenced #$:

INTER>ENTION
ecommended Nutrition Prescri'tion: Cotal caloric intake o! 6 +1+" kcal0da$ )ith total !at intake no more than 8" g0da$ .7"9 total kcal0 da$1 and total saturated !at +7 g0da$ .1"9 total kcal0da$1. Food or Nutrient Beliver$: Meals and Snacks.NB-11: %eneral ;ealth!ul Biet. Patient should consume 6 +1+" kcal0da$( limiting total !at to no more than 8" g0da$ .P7" 9 total kcal0da$1 and limiting saturated !at to no more than +7 g0da$ .P1"9 total kcal0da$1 Nutrition Counseling: N0& Nutrition education: .11 Ceach )hich !oods are high in !at and saturated !at .+1 Ceach ho) !at 'rovides more calories 'er gram than other macronutrients .71 Ceach ho) to make eas$ su#stitutions #et)een high !at items and lo)er !at items Coordination o! Care .re!er to1:

%oal.s1: Prevent additional )eight gain and #egin )eight maintenance #$ reducing total caloric intake to 6+1+"( total !at to less than 8" g0da$ and saturated !at to less than +7 g0da$.

MONITORIN* " E>A?UATION

@ndicators: eduction in total calories( eduction in total !at consumed( reduction in total saturated !at consumed Criteria: educe Caloric intake to 6+1+" kcal0da$( reduce total !at to less than 8" g0da$( reduce total saturated !at intake to less than +7g0da$. &ssess on !uture visits #$ utiliIing +, dietar$ hour recall.