The Sage Colleges- NCP Documentation Form (adapted for NTR

507/407 Counseling)

Student Name: Livija Wells

Patient ID: DW

Reason for Nutrition Consult: Weight Loss

NUTRITION ASSESSMENT
Food and Nutrition Related History:
DW presents that she wants structure and freedom with her meals: the food group plan.
Pt. lives with her husband and daughter in a two-story home- she is able to cook her own meals, and access the
grocery store.
Pt. does not follow any special dietary plan, and eats 3 times a day at regular times- sometimes skipping breakfast.
Pt. complains about appetite and stress.
Pt. enjoys vegetables, and is open to eating anything.
Pt.s job involves being on her feet, is also located in a plaza and is tempted my local eats and persuasive coworkers,
often ends up eating out which leads to excess sodium consumption based on 24 hour recall.
Pt. is not a smoker, but does enjoy two glasses of wine about 3x a week. Pt. also eats dark chocolate every night.
Anthropometric Measurements
Age: 59
Gender F
Ht: 55
~165 cm

Current Wt: 147lbs/ 67kg

IBW: 120lbs/ 54kg
Wt Hx (specify time frame):
N/A
% Wt change: N/A

BMI:
24.5
BMI Classification: Normal
Weight

PMH:
Pt. is on no current medications
Recent surgeries include and elbow surgery (June 2014), hydrocodone/acetaminophen 5/500mg was prescribed
Medical concerns include weight loss
Family history of Cancer and Thyroid Disorder
Pertinent Medications & Dosage
Calcium Supplement with Vitamin D, 600 mg once a day
Estimated Nutritional Needs based
Calories (kcal/kg & total kcal/day)
18-20 kcal/kg
1200-1250 total kcal/day

on 67 kg
Protein (g/kg & total g/day)
2-2.2 g/kg
145 g/day

Fluid (ml/kg & total ml/day)

19-20 ml/kg
1300-1350 ml/day

NUTRITION DIAGNOSIS (1-2, only)

P (problem) Excessive alcohol intake
related to:
P (problem) Excessive sodium intake
related to:

E (Etiology) food and nutrition related

knowledge deficit
as evidenced by:
E (Etiology) Lack of or limited access
to healthful food choices and foodand nutrition-related knowledge
deficit concerning sodium intake
as evidenced by:

S (Signs & Symptoms)

Pt. reports consuming 2 glasses of
wine 3-4x weekly.
S (Signs & Symptoms)
24 hour recall reported intake of
sodium in excess of about 1000 mg
above estimated needs (2300
mg/day).

INTERVENTION (Focus on counseling)

Continue to meet with patient once a week to see progress with limiting alcohol and chocolate intake.
Educate patient on benefits of breakfast and have patient continue a food journal as a reminder to eat breakfast.
Reiterate patient goals in order to ensure patient is achieving those goals in a specific time frame.
Educate patient on risks of sodium and healthy lunch/eating out alternatives.

2015-2016

MONITORING & EVALUATION

Indicators (marker):
Food and Beverage intake
Physical Activity

Case Questions:

2015-2016

Criteria (SMART Goal specific to marker):

Decrease alcohol to 1 glass 3 x a week for 2 weeks, limit
chocolate consumption to 1 individual square 3 x a week
for 2 weeks.
1 hour of physical activity every day for 2 weeks.