NUT SCI 485 NUTRITION DIAGNOSES FOCUSED ASSESSMENT & CARE PLAN FORM Student: Melanie Grosnick Date:

12/2/13

I. CLIENT DEMOGRAPHIC INFORMATION Age: 22 Sex: M Marital Status: Single

II. CLINICAL: BIOCHEMICAL (NC 2.1-2.3) Medical History: Heart Murmur Past medical/surgical history: (include positive family history as appropriate) Knee Scope last summer, affected activity during summer months

Medication History: N/A, not currently taking any medications DRUG NAME PURPOSE/USE POSSIBLE FOOD/NUTRIENT INTERACTION

Laboratory & Metabolic findings: (If available) Not available LAB Calcium Phosphorus Glucose BUN Cholesterol Protein Albumin Bilirubin Alk Phos (ALP) LDH AST (SGOT) Na K Magnesium Amylase Lipase CPK Hg/Ht Creatinine Triglyceride NORMAL 9-11 mg/dl 2.5-4.5 " 70-110 " 7-22 " < 200 " 6.0-8.0 g/dl 3.5-4.8 " .3-1.2 mg/dl 42-121 U/L 94-172 U/L 1-55 U/ml 135-145 mEq/L 3.6-5.6 " 1.6-2.4 " 19-110 U/L 20-190 IU/L 30-180 " 12-16 g/dl 35-50 % .5-1.5 mg/dl 40-150 mg/dl DATE DATE DATE REASONS FOR ABNORMAL

III.

CLINICAL: FUNCTIONAL (NC 1.1-1.4) Problems with chewing or swallowing? Y/N (possible cause and duration): No Problems with nausea and/or vomiting? Y/N (possible cause and duration): No Problems with diarrhea and/or constipation? Y/N (possible cause and duration): No Other:

IV.

CLINICAL: WEIGHT (NC 3.1-3.4) Anthropometric Data: Weight (stated/actual): Stated: 220 pounds; 100 kg Height: Stated (510): 70 inches; 177.8 cm BMI: 31.6 Ideal/Desirable Body Weight (IBW/DBW): 166lbs %IBW: 133% Adjusted body weight (use to determine estimated needs if present weight for men >125% IBW; women >130% IBW): 182lbs How long has client been at present weight? (+/- 5 lb) 2 yrs Has client lost or gained weight before? Yes (unintended) Weight change (loss/gain): Gain: 35 pounds; (% of UBW:19% ) Time period of weight change: 1 year (2 years ago) If there has been a weight change, describe the reason or cause: Unhealthy food, college experience (moving away from home), didnt care, comfort and laziness, fast food/microwave meals

V.

BEHAVIORAL-ENVIRONMENTAL: PHYSICAL ACTIVITY AND FUNCTION (NB 2.1-2.6) Physical activity: describe types and duration of physical activity in typical day/week None, especially during winter months. Much more active during summer (recreational activities) Are there any problems with mobility? Y/N (possible cause and duration): Reoccurring knee issues but none after knee was scoped. Problems with senses (vision, hearing, smelling etc)? Y/N (possible cause and duration): None-wears contacts Condition of skin/hair/nails/oral cavity: Hair: premature grays, but very thick and otherwise good Nails: good, bitten and short Skin: possible acanthosis negricans, previously assessed at dermatologist and was tested for diabetes, but results showed negative. Oral: good dental hygiene, no mouth sores Are there any difficulties with obtaining foods? No. Explain: (transportation financial, time etc)

Who usually prepares the food eaten at home? Mother Who usually goes grocery shopping for the household? Mother Activities of Daily Living and Functional Status: Work: loads and unloads furniture on semis (12-25 hrs per wk, varies)

VI.

BEHAVIORAL-ENVIRONMENTAL: KNOWELDGE AND BELIEFS (NB 1.1-1.7) Education history, Etc: Has client tried to change his/her diet in any way? If so, what type of changes? No-feels no need to change his diet Are there any other members of your household on a modified diet : No. Explain: Previous education (when/by whom): High school health education, college healthy active lifestyle class If there has been previous education, briefly describe your experience (positive, negative, helpful, etc) Very basic educational information, didnt take the information seriously and common knowledge. Are there any issues or special needs associated with educational level or literacy? No Does the person who shops read labels? If so what part of the label influences a purchase? No, name and brand influence purchases made, and requests from family members

Appetite and food preferences: How would you describe your appetite? Good

Has there been a recent change in appetite: No (just a change in type of food being eaten) Explain: Mother cooks meals 2-3 times per week, less eating out and fast foods because not away at college.

What factors most often influence what foods and when you eat? (Hunger, habit, stress, boredom, etc.) Hunger, preference of whats available at home, boredom, if money is available to eat out/order food

What are your favorite foods? Pizza (meat lovers), hamburgers, cheese, lasagna, pancakes, pineapple, Mountain Dew What foods do you strongly dislike? Black olives, seafood-crab, salmon Do you have any food allergies or intolerance? None Do you take any vitamin and/or mineral and/or herbal supplements? If so, what form and what amount? What is the purpose? No Meal Patterns What is your usual meal pattern/day? (# of meals and snacks) 2 meals per day (12pm and 6pm), 2-3 snacks per day (after lunch, late at night) Where do you eat most of your meals and with whom? At dining room table with family How often in a week do you eat out? Specify types of restaurants. 2 times per week. Ex: Applebees, McDonalds, Subway

VII.

NUTRITION INTAKE (NI) Food Preparation: What is the most common method of cooking meats, poultry and fish? (Bake, broil, grill, fry etc) Meats: grilled, baked Poultry: baked, fried Fish: fried What kind and amount of fat do you usually use in cooking? Olive oil, ~2 Tbsp (doesnt usually do the cooking) What kind and amount of fat do you usually add to vegetables, potatoes and breads, etc before eating? Butter, 1 tsp

DIETARY INTAKE: 24-hour recall or typical daily intake Time of Day 12pm Meal or Snack Meal Place Home Detailed Description of Food or Beverage Microwavable chicken pot pie (Marie Calanders) Amount 4 inches in diameter

3:30pm

Snack

Home

Large bowl of cereal (Honey Bunches of Oats) 2% Milk

1 cup 1 cup

6pm

Meal

Home

Meatloaf Mashed potatoes Butter Creamed corn 2% Milk

4 ounces 1 cup 1 tsp cup 1 cup

9pm

Snack

Home

Apple (medium)

12am

Snack

Home

Oatmeal-plain

1 cups

How does the amount of food you described compare with the amount that you usually consume for that day of the week? __________ much more than usual _________ __________ dont know much less than usual

_____X_____ usual

B.

Food Frequency PER WEEK (W) Food Item & Frequency: # of times per d,w,m,or not at all 6. Meats, Fish, Poultry, Eggs Beef 3x Pork 1x Chicken 2x Fish 0x Dairy Products Tuna 0x Pizza 2x Lentils 0x Eggs 1x 7. Sweets, Desserts, Snacks ice cream 1x Doughnuts 0x Cakes 0x Pie 0x Cookies 1x Candy 1x chips, pretzels 2x 8. Alcohol Wine 0x Beer 0x Pasta, Rice Liquor -0x

Food Item & Frequency: # of times per d,w,m,or not at all 1. Breads, Starches Bread 4x Cereal 6x bagel, muffin 0x Other 2. Milk 14x Cheese 5x cottage cheese 0x Other: Yogurt 2x 3. Fruits and Juices Oranges (juice) 6x Bananas 1x Apples 2x Other: V8 juice 1x 4. Vegetables

dark yellow or orange 2x dark green 2x Potatoes 1x Other 5. Spaghetti, noodles 1x Lasagna 1x Rice 0x Other

9. Other Soda (Mountain Dew) 4x

C. Evaluation of nutrient intake 1. Based on Exchange System: (per day) Food Group # of Exchanges 2 slices of bread 1 apple 4 cups cup 4 ounces 1 ounce CHO grams 30 grams 15 grams 48 grams 5 grams 0 0 PRO grams 3-6 grams 0 32 grams 2 grams 28 grams 7 grams FAT grams 1-2 grams 0 20 grams 0 16-28 grams 0-3grams CALORIES 160 cals 60 cals 480 cals 25 cals 300 cals 45 cals

Starch Fruits Milk (2%) Nonstarchy veggies Medium fat beef Lean chicken (in pot pie)

TOTALS:

98 grams CHO

~74 grams PRO

~47 grams FAT

1070 calories

2. Based on MY PLATE Guide: Food Group Portion/Servings 4 cups Dairy Fruits Vegetables Grains Protein Oils 1 cup 2 cups/day 8 oz (1 cup) 6-7 oz 4-5 tsp Portion/Servings recommended 3 cups 2 cups 3 cups 8 oz, >4 oz whole grains 6.5 oz 7 tsp Difference + 1 cup - 1 cup - 1 cup Equal, but no whole grains Equal - 2 tsp

D. Estimated needs: (calories/protein/) - indicate method of calculation Mifflin St. Jeor: B.E.E. = (10 x 100) + (6.25 x 177.8) - (5 x 22) + 5 = 2006.25

E. Evaluation of present dietary practices: Identify: 1) Present practices that support nutrition goal High consumption of fruits and vegetables, eats with family, eats mostly homecooked meals, doesnt consume alcohol

2) Present practices that are not consistent with nutrition goal Eats fast food/at restaurants twice a week, loves beef, bacon and other meats, has friends that consume alcohol a lot (at bars frequently on weekends)

3) Potential barriers to patient making changes Taste of healthy foods, lack to effort to make own meals and cook food, denial of any weight problems, comfort, lack of physical activity, lack of support from family members

4) Supportive factors for patient Girlfriend, swimsuit season/body, wants to be healthy for the future PATIENTS STAGE OF READINESS FOR BEHAVIOR CHANGE (reasons for your assessment) Precontemplation: The client doesnt think this is a problem with this weight gain, just thinks it is a part of life. He has showed no effort to change, has no intent to change in the next 6 months, enjoys watching television and playing video games 5-6 hours a day, might feel as if he is too far gone.

STUDENTS LEARNING ISSUES: What topics or information do you need to research further to complete this care plan? Describe how you obtained this information. I would further research his favorite foods and maybe take another 24 hour recall to see if some days are unhealthier than others. I feel like what he is eating isnt that unhealthy. Although he might be going out to eat a little too frequently, he is making healthy choices when it comes to most meals. I would look into the meals he is having with his family to see if there are possible ways to cook the same meals, or his favorite meals, in a healthier fashion. I would look into beginner cooking classes or find some information for him to see if he would be interested

in learning how to cook his own healthy meals. By personally knowing his family, I know his mother/family are not very conscious of the way they cook meals or what foods are being bought for the family. By learning to cook his own meals or being more educated on nutrition, the client could make healthier choices for himself that might even benefit the whole family! I would also make personal training available to him and see if it fits into his schedule. I think he doesnt want to take the time to go to the gym himself when he doesnt know the correct exercises or what will benefit him the most. Maybe a couple of free personal training sessions with beneficial results will make him realize hes not too far gone and with the correct exercises he could make learn to do it on his own. I know the client is not financially stable on his own, but once he realizes the benefits of personal attention at the gym he would be willing to pay for his sessions. Along with training, I would talk to him about inside activities for winter time. Being a successful high school athlete, I would talk to him about why he was successful then and maybe talk about his weight and how he felt back then. There are also many outside activities I think he would enjoy during the snowy months. The last thing that I would further research is his possible diagnosis of acanthosis negricans. I would request his test results from his dermatologist if they are recent, or take new labs regarding his blood glucose and triglyceride levels. Although the dermatologist did not diagnosis the client with diabetes, he could be in a prediabetes stage that might get worse if he diet isnt closely monitored.

SELF-ASSESSMENT OF INTERVIEW/EDUCATION: Comments regarding: Receptiveness and interest of those interviewed; what went well, what didnt go so well Since the client has an intimate relationship with me, he didnt take the interview very seriously at first. The setting for the interview was rather casual. In a more professional setting the interview would have been taking more seriously. He would jokingly list condiments he didnt like for foods he disliked. But after I stressed the importance, he opened up and became more honest. I think his precontemplation stage of change also partially affected his opinion of the questions I asked. The client was honest about his favorite foods and portion sizes. It was much easier for the client to recall meals and foods eaten the day before (the 24 hour recall) than to the food frequency questionnaire. It was also easier to be more specific on the 24 hour recall. I think he doesnt care about his eating habits or weight, or maybe he was embarrassed to admit that although his eating habits arent the worst, his weight isnt where hed like it to be. I also think that he doesnt feel financially stable enough to make healthier purchases. And because his mother does most of the cooking, he appreciates the fact that he doesnt have to make the effort to make meals himself. These are all personal opinions, and the fact that weve been good friends for a long time before we were in a relationship also affects the knowledge and individual information I know about the client. Not all of this information would be able to be obtained by a nutrition professional. I can imagine it would be very difficult to analyze a clients case by only knowing surface information and vague details. After having several sessions with a client I would guess that the dietitian would develop a closer relationship with the client and gain their trust, but I still think it would be hard to give them the best care without knowing them personally. I understand

that a dietitian cannot have a personal friendship with every, or any, client so this will be a skill I need to develop. I will have to work on analyzing the clients circumstance with as much information that is available to me, and providing the best care I can from that.

PES Statements: 1. Involuntary weight gain (NC-3.4) related to lack of physical activity as evidenced by high BMI and high percentage over ideal body weight. 2. Not ready for diet/lifestyle change (NB-1.3) related to lack of effort to choose healthy foods and participate in physical activity as evidenced by high BMI and involuntary weight gain. 3. Physical inactivity (NB-2.1.) related to lack of effort/care as evidenced by involuntary weight gain. 4. Involuntary weight gain/overweight (NC-3.4) related to excessive calorie intake and unhealthy foods as evidenced by high BMI and high percentage over ideal body weight. 5. Lack of desire to manage self-care (NB-2.3) related to comfort with life and weight as evidenced by no effort to make a change. I felt that the clients lack of physical activity was the most evident. And when analyzing the clients current diet, he already includes some healthy choices into his usual meals. The physical activity PES statements were more relevant than the clients occasional fast food and eating out habits.

Interventions: 1. Collaborate/referral to other providers (RC-1.3) and educate/promote skill development (E-2.5) to encourage beneficial physical activity. 2. Utilize the stages of change model (C-1.4) and motivational interviewing (C-2.1) to implement lifestyle changes 3. Collaborate/referral to other providers (RC-1.3) to support and implement correct physical activity habits 4. Create a general/healthful diet (ND-1.1) and recommend diet modifications (E-2.1) to promote healthier eating habits. 5. Request social support (C-2.5) from family members and use motivational interviewing (C-2.1) to evocate change personal realization in the client

I would first concentrate on the clients readiness to change. Being in precontemplation stage, I would focus on trying to elicit confidence that a change is even possible. I would discuss his past weight, how and why he maintained that weight. I would learn about that part of his life, and I would also discuss his college years and how and why his weight changed. Next I would question his lack of care and try to understand why he feels there is no problem. I would focus on the client, and do my best to work with him to draw out his willingness to change without force and judgment. I would try to stress this importance of making this change, not by telling him he needs to change his diet and physical activity levels, but why making clear the consequences of continuing to be inactive. Because the client is a young male adult, who is rather stubborn, I might utilize the health belief model to emphasize the risk associated with being inactive. Before making use of the health belief model, I would be sure to apply motivational interviewing tactics. I would ask questions such as: What has to be different to make this change more important to you? How would your life be different if you were to make a change in your physical activity level or diet? How confident are you that you could make this change? Do you have a support system to help you make this change? After the motivational interview section, I would make use of the Physical Activity Readiness questionnaire (PAR-Q), Lifestyle Management Form 8.4. See attached. After assessing his readiness to make a change, I would ask the client if they would like to take along some education materials to look over before the next session. The handouts would include material we had already discussed in our counseling session just to reiterate and remind the client of what we talked about. These materials would include Potential Benefits of Regular Moderate Physical Activity, the Lifestyle Management Form 8.1, and Physical Activity Options, Lifestyle Management Form 8.3. See attached. After a session or two with the client I would hope that the client would be closer to the contemplation stage, or possible preparation. At the following sessions, I would reassess his readiness to change, the importance of this change, and how confident the client is that he can make this change. I would see if he would be willing to start making steps towards being more active. I would encourage him to set an activity goal for each week as well as a weight goal for a couple months. At this session I would discuss how to utilize a Physical Activity Log, Lifestyle Management Form, 8.2, and how this could possibly make the change easier for him. See attached. Monitoring and Evaluation: After a couple sessions I would evaluate his log to see if he is being more active regularly. I would analyze his accomplishment of activity goals during this time. I would also reassess his weight as well as BMI to see if he making progress toward his goals.

Summary: From doing this assignment, I learned how to analyze a clients diet, as well as determine their calorie needs and compare it to how much energy the client is actually taking in. I also learned how to assess a clients readiness to change and how to gather materials to encourage a physical activity change. Overall this was a great experience to start developing my motivational interviewing techniques along with utilizing anthropometric measurement tools.