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Nutrition Assessment

Patient name

Nutrition Diagnosis:
{IDNTLIST:19142} related to ***, as evidenced by ***.

The patient meets criteria for {CENMALNUTR:19436}.


The patient does not meet criteria for malnutrition as defined by the Academy of Nutrition and
Dietetics/ASPEN.
Not able to determine if pt meets criteria for malnutrition as defined by the Academy of Nutrition
and Dietetics/ASPEN at this time.

Intervention and Monitoring:


Oral Nutrition: ***
- Diet: Recommend ***
- Supplements: ***
- Goal: ***

Monitoring: ***

Coordination of Care: Following care with team.


- Food Insecurity screening: ***

***
________________________________________________________________________

Intake Summary:
***

Comments:
***

Dx: ***
Hx:
Past Medical History:
Diagnosis Date
Arthritis
Asthma
Back pain
Chest pain
Chicken pox
COPD (chronic obstructive pulmonary disease)
Coronary artery disease
Degenerative disc disease
Diabetes
GERD (gastroesophageal reflux disease)
takes meds
Hypertension
Shortness of breath
Sleep apnea
auto 6-12cmH2O

Past Surgical History:


Procedure Laterality Date
HX ANKLE SURGERY ankle fusion
HX CHOLECYSTECTOMY
HX CORONARY ARTERY BYPASS GRAFT 2009
x5
HX FEMORAL-POPLITEAL BYPASS Left 02/27/2017

Diet Order: DIET CARDIAC W CONSISTENT CARBOHYDRATES

Physical Findings: Nutrition focused physical exam ***. Per RN assessment: ***
Last Stool: 1 (08/31/17 1000), Stool Appearance: Formed (08/31/17 1000)

Anthropometrics:
Height: 5' 7" (170.2 cm)
Admit Weight: 214 lb (97.1 kg) (08/27/17 1121) Stated (08/27/17 1121)
Current Weight: 249 lb 1.9 oz (113 kg) (08/30/17 2000) Bed Scale (08/30/17 2000)
Body mass index is 39.02 kg/(m^2).

Pertinent Meds: MAR reviewed

Reason for Consult/Referral: {REASON FOR REFERRAL:17981}

Care Plan Completed ***

Lab Results
Component Value Date/Time
GLU 176 (H) 08/31/2017 0333
BUN 69 (H) 08/31/2017 0333
CRE 2.57 (H) 08/31/2017 0333
NA 139 08/31/2017 0333
K 3.6 08/31/2017 0333
ALB 2.1 (L) 08/27/2017 1155
MG 1.9 08/31/2017 0333
PHOS 5.5 (H) 08/31/2017 0333
TRIG 157 (H) 04/26/2017 0855
GFR 26 08/31/2017 0333
HA1C 7.2 (H) 08/31/2017 0333