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Sage Dietetic Internship Inpatient NCP Form

Name: Ashley Prendergast


Patient ID: D.D.
Admit Date:
09/26/2015

Current Date:
09/29/2015

Reason for Nutrition Consult: Nutrition Risk for PO intake


Admit Medical Diagnosis: Shortness of Breath

NUTRITION ASSESSMENT
Food and Nutrition Related History:
Pt reports consuming diabetic diet. Stays away from sugar, unhealthy fats, processed foods in general. Pt states when
people give her muffins/cakes, she turns them away or throws them out. Drinks plenty of water throughout day and
favorite food is steamed veggies. Finger sticks at home done 2x/day range from 38-400s as per pt. Pt has history of
noncompliance and was admitted to hospital with blood glucose 656 mg/dL.
Current Inpatient Diet
Feeding Ability
Oral Problems
Order:
Independent
Chewing Problem
CHO Counting
Limited Assistance
Swallowing Problem
Extensive/Total Assistance
Mouth Pain
None of the Above
N/A
Explain:

Explain:

Physical Assessment:
Morbidly obese elderly female, well-kept, glasses, nasal cannula, dentures in good condition with no chewing
difficulties reported. Widespread edema, pt reports weight gain of 9.09kg in 2 months related to fluid accumulation
Anthropometric Measurements
Age:
Gender
Ht:
Current Wt: 108 kg
BMI:
72
Female
155 cm
Admit Wt: 106 kg
44.95
IBW: 56-68.8 kg
Wt Hx (specify time frame): 2
BMI Classification:
months
Obese Class III
% Wt change: 9.2% increase
(fluid)
UBW: 98.9 kg (frequent wt
fluctuations, dry weight
unavailable)
Biomedical Data (list only pertinent nutrition-related labs)
Labs

Date
RBC
Hct
Hgb
Trop
BUN
Glu
HDL
9/28/15
3.33
28.4
28.4
0.15
31
297
29
Inpatient Medical Course Relevant to Nutrition (i.e. surgeries, procedures, tests, I/O, etc.):
Insulin drip to normalize glucose, IV Lasix.
PMH:
CHF, COPD, HTN, DM type II, Anemia
Pertinent Medications & Dosage
Insulin, Lasix
Skin status:
Intact X Pressure Ulcer/Non-healing wound; Braden Score (only when skin is intact): _______________
Comments:

Wounds on LLE and RLE, was going to wound care at nursing home (discharged one day prior to hospitalization)
Estimated Nutritional Needs based on 72.7 kg for energy, 108 kg for fluid and protein
Calories (kcal/kg & total kcal/day)
Protein (g/kg & total g/day)
Fluid (ml/kg & total ml/day)
25-30 kcal/kg & 1820-2200 kcal/day
1-1.25 g/kg & 108-135 g/day
13-18ml/kg & 1400-1900 ml/day

NUTRITION DIAGNOSIS (include IDNT codes)


P (problem) Lack of value for behavior
change related to:

2015-2016

E (Etiology) lack of following nutrition


advice
as evidenced by:

S (Signs & Symptoms) glucose >650


mg/dL upon admission, pt reported
not taking insulin at home, often
arguing with caregivers about eating
habits.

P
(problem)___________________________
____________________________related to:

E
(Etiology)____________________________
________________________as evidenced
by:

S (Signs & Symptoms)

RATIONALE (required section):


1. Discuss reasons for including each abnormal lab:
Abnormally low red blood cells, hemoglobin, and hematocrit indicate anemia
and blood loss (internal bleeding from unspecified location) (1). The patients
doctors ordered an iron supplement and noted that they will pay close attention to
these levels. Elevated troponin related to non-ST elevated myocardial infraction.
BUN above normal levels could be caused by uncontrolled DM and/or recent MI.
Elevation of glucose levels and low HDL cholesterol show the patients
noncompliance with prescribed diets.
2. Discuss justification for choosing method of calculating needs (specify
equations & references used):
In the hospital, it is customary to use 25-30 kcal/kg as an estimate of energy
needs. When a patient is obese (this patient presents with a BMI of 44.95 kg/m2)
we use adjusted body weight for energy. This comes to 1820-2200 kcal per day.
Protein is calculated at 1-1.25 g/kg actual body weight for wound healing on lower
extremities and chronic condition of congestive heart failure as per the Nutrition
Care Manual (2). Fluid recommendations were also obtained from the Nutrition
Care Manual for congestive heart failure. Because this patient presents with CHF
and widespread edema, 1400-1900 ml per day should be provided.

References:
1. Pronsky Z, Elbe D, Ayoob K. Food Medication Interaction. 18th ed. Birchrunville, PA: FoodMedication Interactions; 2015.
2. American Dietetic Association. Nutrition Care Manual. Heart Failure: Comparative
Standards. https://www.nutritioncaremanual.org/topic.cfm?
2015-2016

ncm_category_id=1&ncm_toc_id=8585&ncm_heading=Nutrition
%20Care&ncm_content_id=72727#Overview. Accessed September 29, 2015.

2015-2016