Cheathem_D_NAM_1.1.c.

1_DM_NCP

Nutrition Prescription: Consistent Carbohydrate Diet for DM – 1,654 kcal/day (MSJ w/o Activity Factor for Weight Loss), 83 gm/day of protein (20% of estimated energy
needs), 207 gm/day of carbohydrates (50% of estimated energy needs), 1,652 mL/day (1 mL/kcal).
Assess Priority Diagnosis Intervention Monitoring Evaluation
FOOD/NUTRITION-RELATED HISTORY
Food & Nutrient Intake: Currently the
patient is consuming 100% of her Food and/or Nutrient
provided meals for a Consistent Carb 2-Day
Delivery (ND)
2200 kcal diet. When the pt was asked if Follow-up
she was familiar with a diabetic diet she Decreased Energy Diet -Patient’s diet order
reported that she knows what she is -Recommend changing will have been
supposed to eat but she likes to, “eat what diet to Consistent Carb -Monitor changed to CC 1600
she wants”. Her current diet and intake 1600 kcal Diet. Diet Change kcal Diet
exceed her energy intake by 38%. 2-Week
Limited adherence to
Food and Nutrient Administration: Nutrition Counseling -Goals set by Follow-up
nutrition-related
Consistent Carbohydrate 2200 kcal Diet (C) motivational -Patient will have
recommendations RT
Medication and CAM: interviewing identified a minimum
unwilling or disinterested Motivational
-Elavil QD for Sleep session of 3 goals during
in learning/applying Interviewing
-Coreg BID for Hypertension information AEB motivational
-Utilize motivational -Food diary
-Lasix QD for Edema & Hypertension 1 uncontrolled diabetes with interviewing session
interviewing to help the patterns
-Neurontin TID for Pain blood glucose value of and recall them from
patient set personal compared to
-Metformin BID for Hyperglycemia HbA1C value of 8.0% and memory with 100%
goals that align with the appropriate
-Prilosec QD for Gastroesophageal Reflux patient verbalization of accuracy.
recommended nutrition diabetic
-Roxicodone QID for Pain knowingly not adhering to -Per observation and
prescription. choices and analysis of food diary,
-Livalo QD for Hypercholesterolemia diabetes diet
-Zanaflex BID for Muscle Spasms adherence to the patient will have
recommendations. Self-Monitoring
-Aspirin QD for Heart Stents calorie intake made a more
-Educate the patient on as
-Plavix QD for Heart Stents appropriate DM food
keeping a food diary to prescribed.
-Omnipod Dash Insulin Pod for DM choices and fall within
utilize self-evaluation of
-Zofran TID for Nausea 10% of recommended
meeting appropriate
Knowledge/Beliefs: Patient verbalizes calorie intake of 1600
diabetic diet choices and
that she is familiar with a diabetic diet and kcals/day. (1,440kcals-
adhering to prescribed
knows what she should eat but does not 1,760kcals)
diet of CC 1600 kcals.
comply.
Behavior: Non-compliance is apparent.
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Factors Affecting Access to Food and
Food/Nutrition-Related Supplies: None
Reported
Physical Activity: Mobility is limited
related to osteoarthritis of the right knee.
ANTHROPOMETRIC MEASUREMENTS
Height: 5’3” Weight: 243 lbs
UBW: 240 lbs % UBW: 101%
IBW: 115 lbs % IBW: 211%
BMI:43 kg/m2 No wt change Nutrition Counseling 2-Week
Obese observed (C) Follow-up
BIOCHEMICAL DATA, MEDICAL TESTS,
-Goals set by -Patient will have
AND PROCEDURES Motivational
Lab data: Interviewing motivational identified a minimum
interviewing of 3 goals during
Creatinine: 1.31 mg/dL ­ -Utilize motivational motivational
Obese, Class III RT interviewing to help the session
GFR: 45 mL/min/1.73m2 ¯ interviewing session
excessive energy intake patient set personal
Glucose: 563 mg/dL ­­­ AEB patient’s and recall them from
HbA1C: 8.0% ­ goals that align with the -Food diary memory with 100%
verbalization of not recommended nutrition patterns
Tests: None Reported 2 adhering to diabetic diet compared to accuracy.
NUTRITION-FOCUSED PHYSICAL prescription. -Per observation and
recommendations, current appropriate
FINDINGS: Per NFPE, the patient is analysis of food diary,
diet order exceeding Self-Monitoring diabetic
observed to be morbidly obese with the patient will have
energy needs by 38%, and -Educate the patient on choices and
central adiposity. No fat or muscle wasting made a more
BMI of 34 kg/m2. keeping a food diary to adherence to
was assessed. appropriate DM food
CLIENT HISTORY utilize self-evaluation of calorie intake choices and fall within
Reason for Admission/Assessment: The meeting appropriate as
prescribed. 10% of recommended
patient was admitted for osteoarthritis of diabetic diet choices and calorie intake of 1600
her right knee. Upon admission, her blood adhering to prescribed kcals/day. (1,440kcals-
glucose read to be 563 mg/dL. Both long diet of CC 1600 kcals. 1,760kcals)
acting and rapid acting insulin was
administered to help gain better control of
her hyperglycemia.
Personal History: Patient E.C. is a 67
year old Caucasian female who speaks
English.
Patient/Client/Family Medical/Health
History:
-Pt Medical Hx: T2DM, HTN, COPD,
Cheathem_D_NAM_1.1.c.1_DM_NCP
Neuropathy, Hyperlipidemia, Full
Dentures, Sleep Apnea, Obesity
-Family Medical Hx: Alcohol Abuse, DM,
Heart Disease
Treatments/Therapy: Appendectomy,
Tubal Ligation, Heart Stent, Cardiac
Catheterization, Knee Surgery
Social History: Pt is a former smoker of
36 years with quid date of 7/26/2010. Pt
reports to consume an average of 1 glass
of wine/week. The patient does not report
any drug use.