NUTRITION CARE PROCESS - PATIENT CARE WORKSHEET

Student Name: Elizabeth Hartnett

Assessment Date: 9/1/16 Time: 10:00am

Patient Initials: MB DOB: 10/28/1943 Age: 72 Gender: Female

NUTRITION ASSESSMENT
Check and complete as applicable: 24hr recall (Figure 1), MEDFICTS (Figure 2), nutrient analysis (Figure 3), one
week food analysis (Figure 4), SGA (Figure 5)

Admission Diagnosis: Overweight elderly female

Past Med History: Hypothyroidism, high blood pressure, high cholesterol

Levothyroxine 75Mcg, Lisinopril/HCTZ 12.5mg, Atorvastatin 40mg

Current Diet Order: regular diet

Anthropometric Data:

Ht: __150cm_____ Admit wt: ___63kg_____ BMI: 63kg/ 1.52m = 28 IBW: 22kg x 1.5m2 = 44.55kg-54.45kg

Usual BW: _______62kg ______ % UBW: (63kg/62kg) x100=101.6% % IBW: (63kg/46.5kg) x 100% = 135%

waist circumference __95cm______

Wrist circumference ___13cm____ Frame size____11.5cm- medium_____

TSF__21mm_____ Percentile___25-50%____ MAC _275mm2_____ Percentile__10-25%_______

Calculated AMA __3366mm2_____ Percentile__10-25%___

Food/Nutrition Related History: Weight Watchers

Food & Beverage Intake ESTIMATE ENERGY, PROTEIN, FLUID NEEDS

_____ % intake at meals Estimated current energy needs: _1522 kcal/day method: Box 2-1 text page
23
_____ NPO ______ days Estimated current protein needs:____50__ g Per/day __ method: .8g/kg/day
Estimated current fluid needs:__1890___ mL method: 30mL/kg of body
_____ food allergy/intolerance: weight
Access to Food
Metabolic stressors present:
Feeding Route: _x__oral ___tube ___PN
_____ post-op/surgery
_____ fever/infection Food/nutrition knowledge
_____ wound(s) ] _____ adequate _____ inadequate __x___needs education
_____ trauma/fracture ______ declines education
_____ sepsis ACTUAL INTAKE ___1556__Kcals ________67__g Protein
_____ other Include diet recall and computerized nutrient analysis
Assess for Malnutrition Relevant Biochemical Data, Medical Tests, and
Procedures: Include units of measure and Designate as
_____ intake <75% est energy needs >7 days (mod) high (), low () or within normal limits (WNL).
_____ intake <50% est energy needs for >5days
_____ fat wasting (orbital, triceps, ribs) HCT: 29%() HGB: 12.3 mg/dl (WNL)
moderate
severe Cholesterol: 193mg/dl (WNL) FBG: 99mg/dl
_____ muscle wasting (temporalis, clavicle, shoulders, (WNL)
quadriceps, gastrocnemius) Other: Vitamin D: 28nmol/L ()
moderate
severe Calculated N balance: (use 8 for the UUN value and
_____ edema show calculations)
_____ chewing problem N bal= protein intake - UUN + 4
_____ swallowing problem 6.25
Other nutrition issue:
67g/ 6.25 (8+4) = -1.28

Summary of Nutrition Assessment: Include anthropometric data assessment, energy and protein requirements
versus actual intake data, why you used the dietary assessment method you did, biochemical data and nitrogen
balance data, malnutrition risk and SGA information. Please include other information that would be helpful
to further assess this client.

MB is an overweight 72 year old women with a BMI of 28. First an SGA form was filled out to
assess if she is malnourished, if she has any distinguishing diseases that may affect her nutrition
status, and her stress level. Although she reported she has low to moderate stress there has not
been any dietary intake changes, no gastrointestinal symptoms, and no physical changes except
for gaining about 2 lbs in the past year. She reports that it is because she has had more ice cream
this summer than usual. A 24-hour dietary recall and a MEDIFICTS dietary assessment
questionnaire were used at the first counseling session to determine her usual dietary intake. The
day we recorded was not a typical day for her so she was asked to keep a one-week food diary.
This one-week food diary was put into supertracker.usda.gov to be analyzed as well as the 24
hour dietary recall. Her MEDIFICTS and one week analysis gave conflicting results. On the
MEDIFICTS form her score was a 53 indicating a heart healthy diet but on the one-week analysis
both her total fat and total sodium were slightly higher than the target. This indicates that she did
not recall weekly consumption well or she didnt recall serving sizes well on the MEDIFICTS.
Her average daily energy intake (1442kcal) was slightly lower than her estimated energy needs
(1522kcal). Some days during the week it was higher and some days of the week it was much
lower. Her protein intake (69g) was higher than her estimated needs (50g), which is typical of the
tradition American diet. Her fiber intake was low 11g compared to the recommended 21g/day.
This could be because she doesnt consume many complex carbohydrates and she doesnt
consume enough fruits and vegetables throughout the day. Her height (150cm), weight (63kg),
waist circumference (95cm), wrist circumference (13cm), TSF (21mm) were measured. Her BMI
is 28, which puts her in the overweight category (Mahan and Raymond, 2017). She has a medium
frame size, 11.5cm (Lee and Nieman, 2012). Her MAC and AMA are both between the 10th and
25th percentile. Her nitrogen balance was -1.28 indicating that nitrogen loss has exceeded nitrogen
intake. As stated before her protein intake is sufficient and she does not have any metabolic stress
such as sepsis, trauma, or cancer (Lee and Nieman, 2012). Based on the N balance results I would
request a BUN to see if the N balance is accurate. Her HGB (12.3mg/dl), Cholesterol (193mg/dl-
her own labs), and FBG (99mg/dl) are all within normal limits. The Hemoglobin level (HGB) is
on the lower side of normal meaning that there is a lower count of the protein hemoglobin in her
red blood cells than there should be (Lee and Nieman, 2012). Her HCT (29%) and Vitamin D
(28nmol/mL- her own labs) were both low. We would like to see her HCT to be between 37% to
47% and her Vitamin D level should be >30nmol/L. Her doctor suggested that she take over the
counter Vitamin D supplements but she has not done that yet. On her one week food analysis her
Vitamin D intake was low as well. A low HCT indicates that the percentage of red blood cells in
in the blood is low (Lee and Nieman, 2012). I would ask for a blood test to determine serum iron
and total iron-binding capacity (TIBC) because both her HGB is on the low side and her HCT is
low indicating possibly anemia. With both the serum iron and TIBC the transferrin saturation can
be calculated (Lee and Nieman, 2012). The transferrin saturation level is a better indicator of iron
supply. Her cholesterol is under 200mg/dL and her total cholesterol on her one-week analysis
eaten was under the target of <300mg. She is also taking Atorvastatin 40mg for high blood
pressure and Levothyroxine 75Mcg for hypothyroidism.
(Unintentional weight loss: 10% in 6 months, 7.5% in 3 months, 5% in 1 month, >2% in 1 week)

adequately obese at risk for moderate severe malnutrition

nourished X malnutrition malnutrition

NUTRITION DIAGNOSIS: (Problem, Etiology, Signs/Symptoms Statement)

Inadequate dietary fiber intake as related to knowledge deficit concerning desirable carbohydrate
and dietary fiber quantities as evidence by client reporting that she is on a low-carb diet and
estimated intake of fiber is insufficient when compared to recommended amounts.
Why did you pick this diagnosis?

I chose this diagnosis because after speaking with my client it seemed like one that she is willing
to follow. She is overweight and wants to lose weight but doesnt know how. If she is on a higher
fiber diet she is likely to eat more fruits and vegetable that are lower in calories. This may help
her lose weight because she will be fuller longer (due to fiber) and she will be eating less calories.
It is evident that her fiber and fruit and vegetable intake were all low according to her one week
food diary analysis. Her average daily intake of fiber was 11g, her average fruit intake was cup,
and her average vegetable intake was 1 1/2cups.
NUTRITION PRESCRIPTION: (Recommendation for Diet and/or Nutrition Support)

Recommended 21g/day of dietary fiber on a regular diet.

NUTRITION INTERVENTION: Recommendations/Plan (include referrals needed):

I used motivational interviewing and the strategy goal setting to help my client in identifying her
own dietary fiber related goals. Suggestions from me were: Eat 3-5 servings of vegetables a day
for the next two weeks. Eat beans or nuts/ seeds 2-3 times a week for the next two weeks.
When baking, make half or more of the flour 100% whole wheat flour for one month. When
selecting the goal we made sure the goal was specific, measurable, attainable, realistic, and time
oriented (SMART) (secondscount.org, 2015). She did have a few goals in mind so we evaluated
the pros and cons of each goal and selected the best ones for her at this point. We spoke about
how she planned on achieving the goals and how she would be able to measure it. We talked
about having subgoals related to the main goal but she did not feel it was necessary.
Goals:
I will eat 3-5 servings of vegetables everyday for one month.
I will eat only 100% whole wheat toast in the morning for breakfast for one month.
Nutrition Education: I asked MB if she would like some information on why fiber is important to
her body and if she would like some tips on how to increase her fiber consumption. As she is
concerned about her weight, my education material focused on how dietary fiber can cause early
satiety and may reduce her caloric intake. I told her that dietary fiber adds bulk so she may feel
fuller quicker and longer. I explained to her the difference between soluble and insoluble fiber. I
We spoke about adding fiber gradually into her diet as some fiber rich foods may cause
discomfort. We also spoke about making sure to drink extra water as well. I explained to her
about refined grains vs whole grains and their relation to fiber. She agreed to try to eat more
whole grains when she does eat bread and pasta. I gave her a handout from eatright.org about
fiber with suggestions of high fiber foods (Figure 6) (Larson, 2016).
I explained to her about the supertracker.usda.gov website and the phone app that they have. I
suggested that it could help her keep track of her food easily. She told me she wasnt confident
enough with a computer or phone to do it. She said she didnt mind doing a written food diary.
Expected Outcome(s):

Patient will increase PO intake to ______% of meals/supplements consistently within ________ days
Patient will tolerate tube feeding goal of ___________________________________within ________ days
Patient will meet at least 75% of estimated needs from all sources of nutrient intake within ________ days
x Other: __Patient will increase her daily intake of fiber to 21g/day in the next month
x Patient/family aware of interventions
MONITORING/EVALUATION: (What will you monitor, how often and why? Provide a measurable method of
evaluating the effectiveness of your care plan.)

I scheduled another appointment with MB one month from the initial date. I asked her to keep a three
day food diary just before our next appointment. I will put it into supertracker.usd.gov for her and
print out the Food groups and Calories report and the nutrients report. Specifically I want to measure
her average fruit and vegetable intake, her whole grain intake, and her total fiber intake. I want to keep
track of her total fiber and how she is getting that fiber.

At the next appointment, MB will be asked several question regarding high fiber foods and meals
containing fiber rich foods. This will give me an idea if she has retained the information given to her
at the last appointment.
References:

Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics
Language for Nutrition Care. http://ncpt.webauthor.com. Accessed September October 2016.
Larson H. Easy Ways to Boost Fiber in Your Daily Diet. www.eatright.org.
http://www.eatright.org/resource/food/vitamins-and-supplements/types-of-vitamins-and-
nutrients/ways-to-boost-fiber. Published September 27, 2016. Accessed September 29, 2016.
Lee, R.D. and Nieman, D.C., Nutritional Assessment, 6th ed., McGraw Hill, St. Louis, 2012.
Mahan, L. K., and Raymond, J. L., Krause's Food, and The Nutrition Care Process, 14th edition.,
Elsevier, Inc., MO, 2017.
Setting Goals & Starting a Heart-Healthy Eating Plan. Secondscount.org.
http://www.secondscount.org/healthy-living/healthy-living-detail?cid=14a1b2af-1631-4e88-b456-
589ee370c2e8. Published January 1, 2015. Accessed September 25, 2016.
SuperTracker: My Foods. My Fitness. My Health. (2016). Retrieved September 1, 2016, from
https://supertracker.usda.gov/
ADIME Note: Include only pertintent information

A:

Client is a 72 year-old overweight women: Ht- 150cm, Wt- 63kg, IBW- 44.55kg-54.45kg
Estimated Energy Needs: 1522kcal/day
Her average daily intake from 1 week analysis: 1442kcal/day
Average daily fiber intake: 11g/day compared to recommended 21g/day
Laboratory values: HCT and Vitamin D= low; HGB, Cholesterol, FBG all WNL
D:

Inadequate dietary fiber intake as related to knowledge deficit concerning desirable carbohydrate and
dietary fiber quantities as evidence by client reporting that she is on a low-carb diet and estimated
intake of fiber is insufficient when compared to recommended amounts.
I:

Education: Provided client with information on how to change her diet to include fiber rich foods.
Handouts were given to client to remind her what foods are high in fiber. Planning when to eat more
fruits and vegetables through some meal planning.
Goals: Eat 3-5 servings of vegetables everyday for one month.
When eating grains, make sure 50% of them are whole grains for one month.
M:

Three day nutrient, fruit and vegetable, whole grains intake analysis in one month.
Client will be asked to recall information obtained from the first interview.
E:

Based from the nutrient analysis client is consuming an average of 11g of fiber. Fiber intake will be
measured at next appointment in one month.

Signature: Date: Time: