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Ilyn Mendoza

NUTR 302L
02/07/14
Glucose Assessment Lab
Nutrition Assessment
Diagnosis: Type I Diabetes Mellitus
Nutrition-related PMH, treatments, surgeries: Insulin injections
Age, gender: 24 y/o, male
Dietary intake: Lunch and dinner with infrequent snacks. Poor nutrition choices (High
caloric/high energy, fast food).
Exercise habits: Physically inactive
Knowledge, readiness for change: Not knowledgeable, low readiness for change
Functional/behavioral factors: Inconsistent monitoring of blood glucose
Symptoms: Frequent urination, excessive thirst and hunger.
Anthropometric measurements:
o Ht/Wt: Ht: 510 (177.8 cm), Wt: 165# (74.8 kg)
o BMI: 23.7 (normal)
o IBW: 166# (75.3 kg)
o %IBW: 99.4%, no malnutrition
Energy, protein and fluid needs
o Total energy: 2,334 kcal/d
Used the Abbreviated version, then multiplied REE by activity factor and
injury factor
74.8 kg x 1.0 kcal/kg x 24 hr; x1.3
REE: 1,795 kcal/d
Activity factor: 1.3
Injury factor: n/a
o Protein: 59.84-74.8 g/d
Stress factor used: Non stressed state
o Fluid: 2,996-4488 ml/d
Used 40-60 ml/kg/d
Labs/tests
o Hgb: 14.7 g/dl, normal
o Hct: 44%, normal
o Albumin: 4.3 g/dl, normal
o Glycosylated hemoglobin: 9.4%, high
Medications/supplements: Insulin
Nutrition Diagnosis (PES format)
Excessive energy and carbohydrate intake R/T lack of nutrition knowledge and poor selfmonitoring of Type I Diabetes AEB urination, excessive thirst, hunger and high
glycosylated hemoglobin (9.4%).
Nutrition Intervention
1. Meals and snacks:

o Encourage the consumption of fruit, vegetables, and whole grains in SFM.


o Encourage the reduction of high fat and fast foods in diet.
2. Nutrition Education
o REC nutrition classes related to Diabetes education once a week
3. Nutrition-related medication management
o REC multivitamins to take once a day
Goals
1. Improve self-monitoring habits and check blood glucose on a daily basis.
2. Improve healthy eating habits and reduce the amount of high energy/kcal foods.
3. Normalize glycosylated hemoglobin levels in 6-8 wks.
Nutrition Monitoring and Evaluation
1. Follow up with patient once a week to check patient blood glucose.
2. Administer a three day food record to evaluate dietary changes (if any).
3. Follow up with patient at least two times a month to determine if glycosylated
hemoglobin levels have normalized.

Ilyn Mendoza
NUTR 302L
02/07/14
Albumin NCP
Nutrition Assessment
Diagnosis: Bladder Cancer
Nutrition-related PMH, treatments, surgeries: Decreased appetite since chemo, N/V
when tries to eat
Age, gender: 55 y/o, female
Dietary intake: n/a
Food preferences, allergies, intolerances: n/a
Exercise habits: n/a
Knowledge, readiness for change: n/a
Functional/behavioral factors: n/a
Resources for obtaining, preparing food: n/a
Symptoms: Poor appetite since chemotherapy, nausea and vomiting when patient tries
to eat.
Anthropometric measurements:
o Ht/Wt: Ht: 55 (165.1 cm), Wt: 112# (50.9 kg)
o BMI: 18.7 (normal)
50.9 kg/1.651 m2 = 18.67 kg/m2
o IBW: 125# (56.8 kg)
55 100# + 5#(5) = 125#
o %IBW: 89.6%, mild malnutrition
112#/125# x 100 = 89.6%
Degree of malnutrition: Mild -- 81%-95%
o UBW: 123#, 55.9 kg
o %UBW: 91%, mild malnutrition
112#/123# x 100 = 91%
Degree of malnutrition: Mild -- 81%-95%
o %wt change: 8.9%, mild weight loss
(123# - 112#) / 123 = 0.089; 0.089 x 100 = 8.9%
Degree of weight loss: Mild 6-9%
Energy, protein and fluid needs
o Total energy: 1998-2306 kcal/d
Used Harris-Bennedict formula to determine REE, then multiplied by
activity and injury factor
o Protein: 76.35-89.08 g/d
Stress factor used: Tumor with multiple therapies
o Fluid: 1782 ml/d
Used 35 ml/kg/d
Labs/tests can indicate high or low, normal or abnormal
o Glucose: 83 mg/dl
o BUN: 15 mg/dl
o Hgb: 12.2 g/dl

o Hct: 37%
o Total protein: 5.5 g/dl (low)
o Serum albumin: 2.8 g/dl (low)
Medications/supplements: Chemotherapy
Skin integrity: n/a
Fluid intake/output (I/O): n/a
Bowel movements (BM): n/a

Nutrition Diagnosis (PES format)


Inadequate energy/protein intake, nutrient deficient R/T poor appetite and N/V AEB
8.9% mild weight loss, <90% IBW, low total protein and low serum albumin.
Nutrition Intervention
4. Meals and snacks:
o Provide snacks (ie. Protein supplement shakes) TID in between meals.
o Provide protein rich foods for meals: Beans, legumes, chicken, fish, or eggs.
5. Nutrition-related medication management
o REC appetite stimulant
Goals
1. Dietary intake to meet >75% estimated energy needs.
2. Weight gain of 1#/week until pt reaches UBW/IBW.
3. Normalize total protein and serum albumin levels in 4 wks
Nutrition Monitoring and Evaluation
Follow up with patient within 1 wk and reassess anthropometric measurements (ie. BW,
% wt loss).
Follow up with patients within 2-4 wks to determine if lab results have normalized (ie.
Total protein and serum albumin).
If little to no changes are made within 4 wks, consult MD to discuss advanced nutrition
interventions (ie. TPN).

Ilyn Mendoza
NUTR 302L
02/14/14
Hemoglobin/Hematocrit Assessment Lab
Nutrition Assessment
Diagnosis: Apparently healthy, breastfeeding mother
Nutrition-related PMH, treatments, surgeries: Vegetarian, stopped taking
vitamin/mineral supplement, experiencing fatigue.
Age, gender: 22 y/o, female
Dietary intake: Vegetarian diet , healthy diet
Food preferences, allergies, intolerances: No meat
Knowledge, readiness for change: Low knowledgeable, low readiness for change
Functional/behavioral factors: Stopped taking supplements, no reason stated
Symptoms: Fatigue
Anthropometric measurements:
o Ht/Wt: Ht: 54 (162.5 cm), Wt: 108# (48.9 kg)
o BMI: 18.54 (normal)
o IBW: 120# (54.45 kg)
o %IBW: 90%, mild malnutrition
Energy, protein and fluid needs
o Total energy: 2,104.9 kcal/d
Used the Mifflin-St. Jeor equation, then multiplied REE by activity factor
and added stress factor
10(48.9 kg) + 6.25(162.5 cm) 5(22 y/o) -161; x 1.3 + 500 kcal
REE: 1,233.6 kcal/d
Activity factor: 1.3
Stress factor: lactation, +500 kcal
st
o Protein: 1 6 mo of lactation= 54.2-64.0 g/d, after 6 mo= 51.2-61.0 g/d
Stress factor used: Non stressed state
o Fluid: 1,956-2,934 ml/d
Used 40-60 ml/kg/d
Labs/tests
o Hgb: 9.5 g/dl, low
o Hct: 30%, low
Medications/supplements: Not taking supplements
Nutrition Diagnosis (PES format)
Inadequate iron consumption R/T cessation of vitamin/mineral supplements AEB
fatigue, low Hgb (9.5 g/dl) and low Hct (30%).
Nutrition Intervention
6. Meals and snacks:
o Recommend foods high in iron (non-heme food sources ie. legumes and lentils)
consumed with foods that will increase the absorption rate of iron (ie. Vitamin
C).

o Encourage introducing lean meats to diet (ie. fish and chicken).


7. Nutrition Education
o REC nutrition education classes related to breastfeeding at WIC clinic once a
week.
8. Nutrition-related medication management
o REC vitamins (ie. folate, vitamin B12, iron) with lunch and dinner BID.
Goals
1. Improve supplement intake and take on a daily basis/often.
2. Improve eating habits w/ high iron foods to increase weight and BMI
3. Improve Hgb and Hct levels within 6-8 wks.
Nutrition Monitoring and Evaluation
4. Follow up with patient in 2-4 wks to reassess anthropometric measurements (weight
and BMI).
5. Follow up with patient once a week to check fatigue level and compliance with
supplement intake and dietary changes
6. Follow up with patient every 2 wks to determine if Hgb and Hct levels have improved.

Ilyn Mendoza
NUTR 302L
02/20/14
Triglyceride Assessment Lab
Nutrition Assessment
Diagnosis: Type II Diabetes Mellitus
Age, gender: 37 y/o, female
Dietary intake: High fat, high kcal diet
Anthropometric measurements:
o Ht/Wt: Ht: 51 (154.9 cm), Wt: 152# (68.9 kg)
o BMI: 28.7 (overweight)
o IBW: 120# (54.45 kg)
o %IBW: 144.8%, obese weight status
Energy, protein and fluid needs
o Total energy: 1,587-1852 kcal/d
Used the Abbreviated version, then multiplied REE by activity factor and
added stress factor
68.97 kg x 0.95 kcal/kg x 24 hr
REE: 1,570 kcal/d
Activity factor: Sedentary, overweight (20-25 kcal/kg)
Stress factor: n/a
o Protein: 55.12-68.9 g/d
Stress factor used: Non stressed state
o Fluid: 2,414 ml/d
Used 35 ml/kg/d
Labs/tests
o Albumin: 4.2 g/dl (normal)
o Hgb: 13.4 g/dl (normal)
o Hct: 41% (normal)
o Glucose: 145 mg/dl (high)
o Triglyceride: 250 mg/dl (high)
Nutrition Diagnosis (PES format)
Overweight and obese R/T excessive fat/kcal/CHO intake AEB high BMI (29.7), high
%IBW (144.8%, obese), high triglyceride (250 mg/dl) and high glucose (145 mg/dl).
Nutrition Intervention
9. Meals and snacks:
o Create a 7 day meal plan based on ideal kcal needs.
o Recommend the consumption of more whole foods (ie. fruit, vegetables, whole
grains, legumes) in SFM rather than high fat/kcal options.
10. Nutrition Education
o REC nutrition education/weight management classes once a week.
11. Nutrition-related medication management

REC multivitamins to take once a day.

Goals
1. Improve eating habits and reduce the amount of high energy/kcal foods.
2. Decrease BMI and weight to a healthy value within 8-12 wks
3. Improve blood glucose and triglyceride levels within 8-12 wks.
Nutrition Monitoring and Evaluation
7. Follow up with patient in 2-4 wks to reassess anthropometric measurements (weight
and BMI).
8. Follow up with patient once a week to check dietary habits/physical activity levels.
9. Follow up with patient every 2 wks to determine if blood glucose and triglyceride levels
have improved.

Ilyn Mendoza
NUTR 302L
03/12/14
Cholesterol NCP
Nutrition Assessment
Diagnosis: Obesity
Age, gender: 39 y/o, male
Dietary intake: Poor nutrition choices; insufficient breakfast with high kcal/fat lunch and
dinner
o B: Breakfast cereal with whole milk
o L: Fast food
o D: Meat loaf/fried chicken, mashed potatoes w/gravy, cheesy broccoli, whole
milk
Knowledge, readiness for change: Not knowledgable of healthy foods
Functional/behavioral factors: Consumption of fast foods/high kcal and fat food items
Symptoms: Inability to lose weight after 2 months of visits at a weight loss clinic
Anthropometric measurements:
o Ht/Wt: Ht: 61 (185.4cm) / Wt: 245# (111.3kg)
o BMI: 32.4 (obese)
111.3kg/1.854 m2 = 18.67 kg/m2
o IBW: 184# (83.6kg)
61 106# + 6#(13) = 184#
o %IBW: 143.3%, obese
245#/184# x 100 = 133.2%
Weight status: Obese Over 120%
Energy, protein and fluid needs
o Total energy: 2,706 kcal/d
Used Mifflin-St. Jeor formula to determine REE, then multiplied by
activity and injury factor
REE: 10(111.3kg) + 6.25(185.4cm) 5(39 y/o) + 5 = 2,081 kcal/d
Acitivy factor: 1.3
Stress factor: n/a
Total energy: 2,081 kcal/d x 1.3 = 2,706 kcal/d
o Protein: 89.04-111.30 g/d
Stress factor used: Non-stressed state (0.8-1.0 g/d)
o Fluid: 3,895.5 ml/d
Used adult, 25-55y/o (35 ml/kg/d)
Labs/tests
o Glucose: 93 mg/dl (normal)
o Hgb: 15.2 g/dl (normal)
o Hct: 43% (normal)
o Total protein: 4.5 g/dl (normal)
o Serum albumin: 4.5 g/dl (normal)
o Serum triglyceride: 123 mg/dl (normal)
o Cholesterol: 300 mg/dl (high)

Nutrition Diagnosis (PES format)


Obese, Class I R/T lack of nutrition knowledge and consumption of high kcal/high fat
foods AEB inability to lose weight, 32.4 BMI, %IBW weight status at obese, and high
cholesterol level (300 mg/dl).
Nutrition Intervention
12. Meals and Snacks:
o Create a 2 week meal plan containing a energy/fat modified diet based on ideal
kcal needs.
o REC consumption of more whole foods (ie. fruit, vegetables, whole grains,
legumes).
o REC elimination of high kcal/high fat foods.
13. Nutrition Education:
o REC nutrition education/weight management classes once a week
Recommend classes that emphasize nutrition relationship to
health/disease (ie. CVD).
14. Coordination of Nutrition Care:
o REC referral to exercise specialist at least 3 times/wk.
Goals
1. Reduce the amount of high kcal/high fat foods and improve overall eating habits.
2. Decrease BMI and weight to a reasonable value within 3-4 mo.
3. Improve cholesterol levels within 3-4 mo.
Nutrition Monitoring and Evaluation
10. Follow up with patient once a week to reassess anthropometric measurements (weight
and BMI).
11. Follow up with patient once a week to check dietary habits/physical activity levels.
12. Follow up with patient every 2 wks to determine if cholesterol levels have improved.

Ilyn Mendoza
NUTR 302L
03/17/14
HDL/LDL NCP
Nutrition Assessment
Diagnosis: Coronary artery bypass recovery
Nutrition-related PMH, treatments, surgeries: Family history of heart disease, smoker (2
packs/d), coronary artery bypass graft
Age, gender: 54 y/o, female
Knowledge, readiness for change: Low readiness for change due to excessive smoking
habits
Functional/behavioral factors: Smokes 2 packs/d
Anthropometric measurements:
o Ht/Wt: Ht: 54 (162.6 cm), Wt: 148# (67.3 kg)
o BMI: 25.5 (overweight)
67.3 kg/1.626 m2 = 25.5 kg/m2
o IBW: 120# (54.5 kg)
54 100# + 5#(4) = 120#
o %IBW: 123.3%, obese
148#/120# x 100 = 123.3%
Degree of malnutrition: Obese Over 120%
Energy, protein and fluid needs
o Total energy: 1,717.6 2,126.5 kcal/d
Used Mifflin-St. Jeor formula to determine REE, then multiplied by
activity and injury factor
REE: 10(67.3kg) + 6.25(162.6cm) 5(54 y/o) 161 = 1,258.3 kcal/d
Activity factor: 1.3 (ambulatory)
Stress factor: 1.05-1.3 (postoperative)
Total energy: 1,258.3 kcal/d x 1.3 x 1.05 = 1,717.6 kcal/d
o 1, 258.3 kcal/d x 1.3 x 1.3 = 2,126.5 kcal/d
o Protein: 84.13-100.95 g/d
Stress factor used: Major surgery (1.25 1.5 g/d)
o Fluid: 2,355.5 ml/d
Used 35 ml/kg/d
Labs/tests
o Triglycerides: 188 mg/dL (High)
o Total cholesterol: 216 mg/dL (High)
o HDL: 27 mg/dL (Low)
o LDL: 141 mg/dL (High)
Nutrition Diagnosis (PES format)
Not ready for diet/lifestyle change R/T smoking 2 packs a day with family history of
heart disease AEB recent coronary artery bypass surgery, %IBW over 120% (obese), high
triglyceride levels (188 mg/dL), high total cholesterol levels (216 mg/dL), low HDL (27
mg/dL) and high LDL (141 mg/dL)

Nutrition Intervention
15. Meals and Snacks:
o Create a 7 day meal plan containing an energy modified diet based on ideal kcal
needs.
o REC consumption of whole foods and fiber-rich foods (ie. vegetables, fruit,
whole grains).
16. Nutrition Education:
o REC nutrition education/weight management classes 2 times/wk
o Recomment classes that emphasize nutrition relationship to
health/disease (ie. CVD)
17. Coordination of Nutrition Care:
o REC referral to exercise specialist at least 3 times/wk.
o REC smoking education class at least once/wk
Goals
1. Reduce smoking habits from 2 pack to 1 pack within 3 months and stop smoking completely
within 6 months.
2. Adapt regular exercising habits and maintain a healthy weight, BMI and %IBW.
3. Normalize triglyceride, total cholesterol, HDL and LDL levels in 4-6 wks.
Nutrition Monitoring and Evaluation
Follow up with patient within 1 wk and reassess anthropometric measurements (ie.
weight, BMI, %IBW).
Follow up with patients every 2 wks to determine if lab results have normalized (ie.
triglyceride, total cholesterol, HDL/LDL).
Follow up with patient once a week to check adherence to dietary habits, physical
activity level, and participation in education classes.

Ilyn Mendoza
NUTR 302L
04/17/14
Calcium NCP
Nutrition Assessment
Diagnosis: Excessive calcium intake and overweight
Age, gender: 67 y/o, male
Knowledge, readiness for change: High readiness for change due to concern about
general health
Anthropometric measurements:
o Ht/Wt: Ht: 58 (172.7 cm), Wt: 166# (75.3 kg)
o BMI: 25.2 kg/m2 (overweight)
75.3 kg/1.727 m2 = 25.2 kg/m2
o IBW: 148# (67.1 kg)
58 100# + 5#(8) = 148#
o %IBW: 112.2%, overweight
166#/148# x 100 = 112.2%
Degree of malnutrition: Overweight Over 110%
Energy, protein and fluid needs
o Total energy: 1,953.12 kcal/d
Used Mifflin-St. Jeor formula to determine REE, then multiplied by
activity factor
REE: 10(75.3kg) + 6.25(172.7cm) 5(67 y/o) + 5 = 1,502.4 kcal/d
Activity factor: 1.3 (ambulatory)
Stress factor: n/a
Total energy: 1,502.4 kcal/d x 1.3 = 1,953.12 kcal/d
o Protein: 60.24 75.4 g/d
Stress factor used: Non stressed state (0.8 1.0 g/d)
o Fluid: 1,882.5 ml/d
Used 25 ml/kg/d
Labs/tests
o Albumin: 3.8 g/dl (normal)
o Glucose: 112 mg/dl (normal)
o Cholesterol: 188 mg/dl (nomal)
o Triglycerides: 89 mg/dl (normal)
o Serum calcium: 9.5 mg (normal)
o Urinary calcium: 300 mg (High)
Nutrition Diagnosis
Inadequate calcium intake and overweight R/T excessive/inadequate nutrient intake
AEB high urinary calcium (300 mg), high BMI (25.2) and high IBW% (112.2%,
overweight).
Nutrition Intervention
18. Meals and Snacks

o Create a 7 day meal plan based on ideal kcal needs.


19. Nutrition Education:
o REC nutrition education classes once a wk
o Recomment classes that will educate patient on high calcium foods and
how to consume a balanced amount of nutrients.
20. Coordination of Nutrition Care:
o REC referral to exercise specialist at least 2 times/wk
Goals
1. Improve eating habits and reduce calcium intake
2. Normalize urinary calcium level within 4-6 wks.
3. Decrease BMI and weight to a healthy value within 8-12 wks.
Nutrition Monitoring and Evaluation
Follow up with patient in 2-4 wks and reassess anthropometric measurements (ie.
weight, BMI, %IBW).
Follow up with patient once a week to check adherence to dietary habits, physical
activity level, and participation in education classes.
Follow up with patients in 2 wks to determine f urinary calcium levels have normalized.