Student Name: Gina Ghilani

Patient Name: Mrs. Jones

Nutrition Assessment:
Client History:
48-year old, female
Married with 2 adult children and 2 teenagers and grandchildren
Works part-time (4 days a week) as a secretary for a construction company
Watches grandchildren other day and some weekends
Family history: father and grandmother->diabetes
Brother-> hypertension
Second two children had high birth weights: 9lbs, 6oz & 10lbs, 3oz
Food & Nutrition History:
Has been on and off diets throughout life
-Most recent was Adkins diet (4 years ago) lost 35# but gained 55# back
after stopping
Takes a multivitamin
No nutrition related background
Knows how to read food labels from being on the Adkins diet
Doesnt like dry meats -> example: baked chicken
Doesnt like seafood
Doesnt drink milk
Does all of the meal planning, grocery shopping, and cooking for family
Grocery shops at Kroger once every 3 weeks
Shops primarily for canned, frozen, shelf stable, and convenience foods
Eats out frequently and snacks on vending machine snacks at work
Inactive at work and at home
Used to take walks frequently and would like to start again
-Sometimes takes grandchildren for walks (not often)
Has motivation to change (8 on scale) but is hesitant about getting family on
board
-Has tried making healthier meals in the past and family does not support or
like foods
- Would like some recipes and ways to get family on board
Needs a support system
Eating a diet full of convenience foods that are high in fats and
carbohydrates
Eating 165% over estimated daily intake kcals
Fat intake 212% over estimated intake
Anthropometrics:
Height: 55 -> 65in -> 165cm
Weight: 175# -> 79.54kg
BMI: 29.4 -> overweight

Most comfortable at 150#

IBW: 100 + 5(5) = 125 +/- 10%
IBW%: 175/125 = 140%
UBW%: 175/150 = 117%
Biochemical/Tests/Procedures:
Fasting Glucose 140mg/dl -> high
Hgb A1C: 7.1% -> high
Albumin: 4.0mg/dl
Total Cholesterol: 245mg/dl -> high
LDL: 100mg/dl > near optimal
HDL: 33mg/dl > low, poor
TG: 150mg/dl- borderline high
Nutrition Focused Physical Findings:
Seems a little sad
Sleeps 7-8 hours a night but has a low energy level
Blood Pressure: 128/90 -> high
Comparative Standards:
MSJ: 10(79.54) + 6.25(165) -5(48) 161 = 1425.25
REE: 1425.25 * 1.25 * 1 = 1781.56 kcals
Protein Needs: 0.8 * 80 = 64kg
Fluid Needs: 30 * 80 = 2400
Calories: 2933/1781.56 = 164.6%
Fat: 1782 * .30 = 534.6/9 = 59g
124.8/59 = 212%
Protein: 1782 * .15 = 267.3/4 = 66.8g
93.8/66.8 = 140%
Carbohydrates: 1782 * .55 = 980/4 = 245g
373.5/245 = 152.4%
Assessment Statement:
Mrs. Jones, a 48-year old female, came in on advice from her physician with
goals to lose some weight and to take steps toward a healthier lifestyle. Mrs.
Jones is married with two adult children, two teenagers, and grandchildren.
She works part-time as a secretary and watches her grandchildren when she
is not at work. She is willing to make changes and has motivation to change.
Mrs. Jones did seem a little anxious and explained that her family has not
been supportive of making changes to their food when she has tried to eat
more healthy in the past. She would like some tools and recipes to get her
family on board. Mrs. Jones weighs 175lbs (29.4 BMI, 140% IBW) and is the
heaviest she has ever been and is classified as being over weight. Her
current diet consists mostly of fast food and convenience foods that are high
in fat (212% beyond her estimated fat intake), sugar, and calories (165%
beyond her estimated calorie needs). Mrs. Jones does all of the meal

planning, grocery shopping, and cooking for her family. She typically shops at
Kroger, once every 3 weeks, buying mostly canned, frozen, shelf stable, and
convenience foods. Mrs. Jones is not meeting her fluid needs (64% of her
estimated needs were met) and a majority of her fluid intake comes from
coffee, soda, and other sugar filled drinks resulting in her being at risk for
dehydration. She has a family history of diabetes and her brother has
hypertension. By looking at her lab values, Mrs. Jones has a high fasting
glucose level (140mg/dl), high total cholesterol (245mg/dl), poor LDL
cholesterol (33mg/dl), borderline high triglycerides (150mg/dl) and high
blood pressure (128/80). She also lives a sedentary lifestyle. Her current diet,
lab values, and sedentary lifestyle put her at a high risk for stroke,
cardiovascular disease and heart attack. Her fasting glucose values, family
history, and due to her second two children being about 10lb babies, she is
at high risk for diabetes. Her fasting glucose may need to be rechecked.

Nutrition Diagnosis/Goals:
Diagnosis 1: Overweight related to undesirable food choices as evidence
by being at highest weight in lifetime, 140% IBW, 29.4 BMI (overweight), high
fasting glucose level, high cholesterol, and high blood pressure (128/90), fat
intake 212%, 165% kcal intake, and eating a diet high in convenience foods
and fast foods.
Diagnosis 2: Excess energy intake related to self monitoring deficit as
evidence by large portion sizes via food record, 140% IBW, 165% kcal intake,
212% fat intake, eating a diet high in convenience foods and fast foods and
sedentary lifestyle.
Nutrition Interventions:
Nutrition Rx: 1800-2000kcal diet, general healthy diet
Interventions: Purpose is to establish new healthy habits that aide in
weight loss and improve lifestyle
Relationship to Disease: At risk for diabetes, hypertension, and
cardiovascular disease with family history of diabetes and high glucose
levels, high total cholesterol, borderline high triglycerides, and high blood
pressure.
Education:
Modifications:

1.Decrease total kcal intake by packing lunches and snacks, looking up kcals
at restaurants, swapping out fried sides for healthier options, recipe
makeovers, portion control and using an app to input meals
2. Increase physical activity by getting up more often at work to walk around,
taking grandchildren to parks and on walks, taking daily/nightly walks for at
least 30 minutes, and using a pedometer to track steps and to set goals such
as 10,000 steps
3. Gaining family support by getting kids and husband involved in weekly
meal planning by using a meal planning sheet and making over recipes that
they enjoy but also fit lifestyle change
Applications:
-Meal planning
-Reading restaurant menus for kcals and fat content
-Healthier recipes via Cooking Light website
-Using MyFitnessPal app
-Portion Control
-Using a pedometer
-Incorporating more walking into the day
Counseling Techniques:
-Motivational Interviewing to get a better understanding of the patient and
showing empathy as well as motivating them to do the talking.
-Health Belief Model to understand the patients beliefs and how these
influence their behavior. It can help to see any barriers present for the
patient.
-Goal Setting with goals the patient comes up with that are specific,
measureable, attainable, realistic, and timely so the patient isnt taking on
too much at once.
Referral of Care: Doctor approval for increased physical activity
Labs rechecked 6 months
Goals:
1.Patient will chose side salads or vegetable options in place of french fries
and high fat/fried sides when eating out
2. Patient will wear a pedometer and do 10,000 steps or walk 30-minutes a
day three times a week
Monitoring and Evaluation:
(Criteria/ Parameter)
-Monitor total kcal intake and total fat intake via app or food record with a
goal of 1800-2000 kcals per day and <35% fat
-Monitor portion sizes at meals via food record or app

-Monitor food record or app for recipe modifications with goal to incorporate
whole grains and lower fat intake
-Monitor food record or app for healthier sides while at restaurants with goal
of 3 days a week
-Monitor weight loss with a goal of 1-3# by next meeting
-Monitor lab values via recheck in 6 months with goals to lower fasting
glucose levels <100-120, cholesterol <245, and lower blood pressure