Nutrition Care Process Project

Theory of Medical Nutrition Therapy

Paige ONeil

April 4, 2017
PART 1A- Nutrition Assessment

1. SCREENING

Nutritional Risk Score- 2002

Impaired nutritional status score= 2, moderate (weight loss > 5% in 2 months)

Impaired severity of disease score= 1, mild (diabetes)

Total score= 3- moderate, start nutritional support

2. INTERVIEW

Client History

-What is your diagnosis?

-Do you have any allergies?

-Have you had any recent procedures done?

-Are you physically active?

-Do you take any medications?

-Do you use any supplements? Herbs?

Food/Nutrition History

-How is your appetite?

-Do you have any chewing or swallowing problems?

-Do you have access to food?

-Where do you usually eat your meals?

-Who does the food shopping?

-Who prepares the meals?

-How often do you cook?

-What does an average meal day look like?

-How many meals do you eat per day? Snacks?

-Do you have any dietary restrictions?

-What foods do you not like?

-What foods do you like?

-What types of fluids do you drink? How much?

-Do you eat around the same times every day?

Anthropometric Data

-What is your age?

-What is your weight?

-Is this your usual weight? If no, what is your usual weight and when did the change occur?

-How long ago did the weight change occur?

Biochemical Data- this can be found stapled to the back of the project

Nutrition Focused Physical Findings- this can be found on the Encounter Summary Form

ASSESSMENT OF INTERVIEW

Before the interview with my client, I gathered a list of questions that would cover the five

components of data required for a nutrition assessment. After gathering my questions, I met with

my client and asked her those questions. As this was happening, other questions seemed to come

up to further explain her answers. After the interview was over, I reviewed and completed the

encounter summary form with no problems. I had asked all the questions that I needed to in order

to complete this task.

3. DIET ANALYSIS- this can be found stapled to the back of the project

4. NUTRIENT NEEDS

Total estimated energy requirements- Mifflin-St. Jeor

9.99 x weight(77.27) + 6.25 x height(63) 4.92 x age(25) 161= 1,488-500= 988 kcals/day

This number seems very low; therefore, her total should be 1,200 kcals/day

Protein- .8-1.0/kg RDA

77.27 x .8= 62 grams

77.27 x 1.0= 77 grams

I recommend using 70 grams because it is the midpoint between 62 and 77, so if my client goes a

little over or under that number it will still be acceptable.

Fluid needs- 40mL/kg

40 mL x 77.27= 3,090 mL or 13 cups

5. EVALUATION OF 24 HOUR RECALL

My client had an overall intake of 1087 kcals, which came close to my calculation of 1,200 kcals

per day and is therefore adequate but I would like to see a slight increase. The protein

recommendation I calculated was 70 grams per day, however, my client had only consumed a

total of 54 grams on the day of the 24 hour recall, which was not adequate. Her carbohydrate

recommendation was between 250-360 grams per day and she consumed only 112 grams, which

is not enough. As for fat, it was suggested that her intake would be between 48-85 grams per

day, she consumed 51 grams, which was adequate. My clients saturated fat intake was below 22

grams which was suggested. Her linoleic acid level was 13 grams, which is just over the

suggested amount by 1 gram. Her linolenic acid level was .55 grams so it should be raised to 1.1

grams. My clients fiber was at 25 grams, which was adequate. Her thiamine intake should be at

1.1 mg, however her intake was .78 mg, which was not enough. Her riboflavin level should be at

1.1 mg, and her intake was 1.31 mg, which is adequate. Her intake of niacin should be 14 mg,

however she had only consumed 12 mg, which should therefore be increased. My clients B6

level was recommended to be 1.3 mg, but she had only consumed 1.16, which should be

increased a little bit. Her B12 should be at a level of 2.4 mg, and her intake was 2.28, which was

adequate. Her folate was recommended to be 400 mg, and she consumed 461 mg, which was

adequate. Her vitamin C level was 137 mg which was good because the suggested amount is 75

mg. My clients intake of Vitamin D was severely deficient; she needs 15 mg and only consumed

1.81 mg. Her vitamin A recommendation was 700 and she took in 1712 mg, which was enough.
Her alpha-tocopherol intake should be at 15 mg however her intake was only 6.71 mg, which

was not adequate. Her mineral intake was not adequate as well. The recommendation for calcium

was 1000 mg and she only consumed 623 mg. The recommendation for iron was 18 mg and she

only consumed 10.09 mg. The recommendation for magnesium was 310 mg and she only

consumed 269 mg. The recommendation for potassium was 4700 mg and she only consumed

2714 mg. The recommendation for zinc was 8 mg and she only consumed 7.19 mg. My clients

sodium level was also too high at 4232 mg when compared to the recommendation of no more

than 1500 mg per day. This evaluation suggests that her macro and micro nutrient needs were not

met.

7. ASSESSMENT OF DIET ORDER

I do not agree with my clients current diet order due to the fact that she is deficient in most of

her micronutrients as well as minerals. I would therefore suggest that she consume a variety and

higher frequency of fruits and vegetables that will boost her micronutrient and mineral levels.

Some of these changes may include adding banana, green beans, avocado, cantaloupe, or

peppers. She had told me that this was a good meal day for her because she did not consume

any snacks. On a usual day, she eats snacks such as Oreos, chips, salsa, and pretzels.

8. RATIONAL FOR CLIENTS NUTRIENT RISK CATEGORY

I chose a low nutritional risk category for my client because she has extensive knowledge about

her condition and how her food choices will affect her body. Although she tries to make good

food choices regularly, she is lacking important nutrients and could benefit from nutrition

education.

PART 1B- Nutrition Diagnosis/PES statements

NUTRIENT DIAGNOSIS

1) Overweight/obesity- NC-3.3

2) Inadequate carbohydrate intake NI-5.8.1

3) Inadequate mineral intake- NI-5.10.1.3