Patient:

Referred for:

Nutrition Related History: Pt reports having a fair appetite; was able to consume I00%of breakfast: eggs, home fries, muffin, juice, coffee. At home pt usually has bagel w/ crm chz or cerealfor breakfast, skips lunch, and has some type ofimeat/starch/veggie for dinner or will go out for dinner. Pt admits to excessive snacking on ice cream, cakes, cookies, and chips esp. at night. Pt used to drink soda constantly, but is now drinkingicedteaandjuiceseveraltimes/dayinstead. Ptstateswthasbeenaround360#5-6years. Ptreportshavingactivejobbutnotbeingable to loose any wt even after cutting soda from diet.
Food and

Anthropometric Measurements
Age: 45

Gender: Male

Ht:75"

Wt: 350# Wt Hx: 350-360# for past 5-6 years % Wt change: n/a
BUN

BMI: 43.74-Morbid Obese

Biomedical Data, Medical Tests & Procedures

Labs/Date
2/17

10 n/a n/a nla t.4 1,42 3.6 nla Medical Diagnosis: Possible gastroenteritis Relevant Conditions: abdominal pain, vomiting, chest/back pain PMH: HTN, CHF/SOB, nonischemic cardiomyopathy, cadiac cath9l20t3, sleep apnea Fam Hx: n/a Pertinent Medications: Coreg 1-2.5mg 2xldaV, Lisinopril 2Omelday, Lasix 40mg/day, Potassium 20mEq/day, Colace 100mg/day, Protonix

/t4 I

Albumin
2.7

l, |

Glucose
1.1.2

bAlC

Creat

Na+ |

K+

Hsb

Hct

MCV I

Other nla

!Qr!!y

Skin

status: X tntact n

Pressure Ulcer/Non-healing wound; Comments:

Phvsical Assessment:

Estimated Nutritional Needs Based on Comparative Standards: Protein:0.8-1glday Calories: Mifflin St. Jeor x 1.3 activity factor I2-/-t56glday 2561-2861"kca1 (-1000kcal/day to promote wt
loss)

FIuid: 30ml/kg a.8L/day

Diet Order:
CardiaC/DASH diet

Feeding Ability

Oral Problems

nta ke

X tr n n

lndependent Limited Assistance Extensive/Total Assistance

N/A

n I n X

Chewing Problem Swallowing Problem

Mouth Pain
None of the Above

X n I n
N

eood (>7s%)
Fair (approx. 50%) Poor (<50%)

Minimal
NPO

(<25%)

tr
P

No Nutritional Diagnosis at this

time

X
E

Proceed

to Nutrition Diagnosis Below

(problem) Overweight/Obesity (NC-3.3) related to:

P

(Etiology) excessive energy intake and physical inactivity as evidenced by:

E

(problem) related to:

tP

(Etiology)
as evidenced by:

& Symptoms): BMI of 43.74 and reports of overconsumption of calorie-dense foods. S (Signs & Symptoms)
S (Signs

, b t,u'

,t'.i

1 Y.12.

v.,

";

?
7:_

r,.

1'A

tY-. t.t-t x, * \.,' i

"

Nutrition Prescription: recommend calorie modification: 2561-2861kcal -1000kcal/dayto promote wt loss, 127-159g/day protein,4.8Lfluids Nutrition education: Content (E-1): written/verba I DASH diet edu, Food or Nutrient Delivery: Mealand Snacks (ND-1) - DASH diet/general
healthy eating importance of healthy weight and eating, Application (E-2): mvplate/food groups, portion control Coordination of Care (refer to): n/a
loss

Nutrition Counseling: n/a

Goal(s): Promote safe lndicat{) rs:

wt

of 1-2#/wk
Criteria:

weishl

3I

I-2# wt loss/wk

)
I

ntdrn'l

SiEn atu re

^rw

L/

3ti7

A i,r
Preceptor's Signature

'(il?:.'

jiln
Date

201.3

SGS DI