OUTPATIENT NUTRITION CLINIC

Date 12/1/2016

Name Kunicki, Elena epk5092@psu.edu 12/12/1996

(Last, First) (PSU email) (Date of Birth )

Assessment Chief complaint/reason for visit: Patient is having infrequent bowel movements (sometimes only having
one movement every other day), and complaining of constipation and hard stools when she is having
them. The patient also is having trouble losing weight despite being in a caloric deficit and exercising 6
times a week.

Diet History/Meal Pattern (use your 24 hour recall dietary analysis from PAA #3 to discuss the overall
pattern of the diet (e.g., use the food groups), consider nutrient and caloric intake that is over or under
recommendations, timing of meals or snacks if this is pertinent information for your situation. Do not
write down the foods you listed in your 24 hour recall, but rather summarize in paragraph form the
issues you see in the diet.

The patient is currently consuming a high protein diet (over 40% of calories) while under consuming
carbohydrates (36% of calories) and on the lowest end of the spectrum for fats (25% of calories). The patients
total energy intake is only 68% of the energy she needs to maintain energy balance. She is also only meeting half
her fiber needs, as well as being below her linoleic and linolenic acid needs. The patient is under-consuming
calcium and iron, as well as potassium while over consuming sodium. Finally, the patient is not meeting her
Vitamin A, D and E needs.

Nutrition Supplements (write N/A if none)

CLA (conjugated linoleic acid) Tablets, Whey Protein Powder Supplement

Physical Activity (i.e., sedentary, low active etc.)

Active: performs 60-90 minutes of vigorous exercise 6 times per week as well as daily tasks such as walking
to and from campus.
Food allergies / Intolerance (write N/A if none)

N/A

Medical diagnosis related to this visit (write N/A if no medical diagnoses present)

N/A

Pertinent past medical or nutrition history (write N/A if none)

Last blood test results showed deficiencies in serum iron, iodine and vitamin D as well as low thyroid
hormone.

Adapted from Hershey Medical Center Nutrition Services Form

Medications (write N/A if none)

Cryselle (Oral Contraceptive)

Vital signs (list your pulse and blood pressure taken during lab)

Blood Pressure is 105/52. Pulse is 49 ppm

Anthropometric Data

Female 168.5 122.4 -

19 151 lb 24.2
cm 142.5 lbs

Age Gender Ht Wt Ideal BMI

(in years) body wt

Based on BMI, patient is: (Check one) underweight normal weight overweight obese

Energy and protein needs:

based on actual 54 g/day protein based on actual weight

weight
2200 kcals/day
Estimated kcalorie Indicate if based on actual, Estimated protein Indicate if based on actual
needs/day or ideal wt. needs/day (calculate or ideal wt.
(TEE using MSJ) using protein RDA 0.8g/
kg of body weight or
value from
SuperTracker profile)

Patient understanding (check one): Good Fair Poor

Expected compliance (check one): Good Fair Poor

List Anticipated Barriers to change / Barriers to learning

-Patient is consuming a very regimented/habitual diet and may be unwilling or have issue changing this
-Patient has been consuming a generally low-calorie diet for about 4 years now and may worry about
consuming more calories, fats, carbs, etc.

Adapted from Hershey Medical Center Nutrition Services Form

 Nutrition Write a PES Statement. The statement should address a distinct problem. It should address a
Diagnosis nutritional problem identified by your Nutrition Assessment (suggestions to help you identify your nutrition
problem: look at total energy intake, intake nutrients highlighted in PAA #3, look at your MyPlate results etc.) Note:
you dont have to use these if you have another problem that fits your situation. Problem must be from Nutrition
Diagnostic Terminology Sheet and include Code.

Inadequate fiber intake (NI- 5.8.5) related to consumption of only 14 g out of the recommended 26 g daily
fiber, as evidenced by constipation, infrequent bowel movements, and weight loss plateau.

Intervention/ For the PES statement listed above, write one intervention statement and 2 goals. Your intervention and
Goals goals should solve the problem you identified in the PES statement. Note: use the Intervention
terminology and code in the Resource File to write your Intervention statement. Remember that your
goals must be specific and measureable.

Intervention Statement for PES Statement

Increased fiber diet (ND-1.2.7.1) by way of increased intake of whole grains, fruits and vegetables.

Write 2 goals you plan to set for the patient to resolve the nutrition problem stated in PES Statement
remember each must be measurable and specific (i.e. include numbers and time frames)

Goal #1:

Increase fiber intake to at least 26 g/day for 2 weeks and keep track of changes in bowel movements
aiming for at least one regular movement per day.

Goal #2:

If normal bowel movements resume, continue with increased fiber intake and re-test body weight after about a
month. Aim for body weight of around 142 lbs, or about an 8 lb decrease.

Mark all that apply: If you were educating a real client, what would you do?

Instructed on diet or intervention as stated above

Adapted from Hershey Medical Center Nutrition Services Form

 Reviewed adequacy of diet based on MyPlate

Discussed current food choices and alternatives

Discussed relevant medications and/or supplements

Write down the educational materials you might use with your client to help him or her meet their goals.
(Note: you can make up something, but be realistic).

I would personally recommend good sources of dietary fiber to my client as well as help them plan how they
may incorporate these high fiber foods in to their normal diet. I would also encourage them to research recipes
containing these high fiber foods.

Follow Up 12/4/2016
Elena Kunicki Daily Iron Intake, Current Weight Status
Appointment
(Dietitian to see (that is you)) (Date) (Key topic to discuss)

Adapted from Hershey Medical Center Nutrition Services Form