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Nutrition Assessment Patient Interview: C/O Losing a tremendous amount of wt. Terrible diarrhea for a long period of time.

Substantial lack of energy. Admitting Dx: Celiac disease with 2° malabsorption and anemia__ PMH: 3 pregnancies: 2 live, 1 miscarriage 22 weeks Patient is a _36_ y/o white _ _female___ Ht. _5’3’_Wt. _92 lbs__BMI _16.3_ %IBW_80%__ %UBW_82%__ UBW timeframe: _3 months_ Diet order: 100g fat x 3 days Average Meal Intake: AM – 1 slice whole-wheat toast, 1 tsp butter; hot tea with 2 tsp sugar Lunch – 1 c chicken noodle soup, 2-3 saltine crackers, ½ c applesauce, 12 oz Sprite; throughout rest of day, sips Sprite Dinner - None I/O’s: N/A GI: Small bowel biopsy indicates flat mucosa with villus atrophy and hyperplastic crysts – inflammatory infiltrate in lamina propria. Fecal fat indicates steatorrhea and malabsorption. Pertinent Labs: (Albumin 2.9g/dl, Prealbumin 13 mg/dl, Hemoglobin 9.5 g/dl, Hematocrit 34%, Ferritin mg/ml, B12 21.2 ng/dl, Folate 3 micro-g/dL) Pertinent Medications: Prenatal vitamins (1 daily), and Kaopectate (2tbsp every 3-4 hours). Physical exam/skin: General appearance is thin and pale. C/O fatigue, weakness, and diarrhea. Skin is pale without lesions. Diminished bowel sounds. Other info:

************************************************************************ Nutrition Diagnosis/Diagnoses: (PES Statements) 1. Inadequate oral intake (NI-2.1) related to patient’s aversion of food because it causes her diarrhea as evidenced by severe unintentional weight loss. 2. Food and nutrition-related knowledge deficit (NB-1.1) related to a new diagnosis of celiac disease as evidenced by the patient’s 24-hour diet recall where consumption of gluten-containing foods was reported.


Nutrition Intervention: Individualized Treatment Goals to Address Nutrition Diagnosis 1. The patient will regain a normal PO intake adequate for her size and nutrition needs. 2. The patient will be able to explain what gluten is 3. The patient will be able to read a food label and identify whether it may contain/be contaminated with gluten. 4. Patient will be able to list a few gluten-free alternatives to products she already uses. Intervention Statements (Use Intervention Sheets) 1. Modify distribution, type, or amount of food and nutrients within meals (ND-1.2). 2. Nutrtition relationship to health/disease (E-1.4). ************************************************************************ Monitoring and Evaluation 1. Monitor food intake to ensure adequate kcalories. 2. Check lab values for prealbumin to see an improvement in protein status. 3. Ability to adhere to a gluten-free and lactose-free diet. 4. Evaluate bowel movements to indicate return of normal GI functioning.

Signed _____________________________________ Date: ______________________