Student Name: Marisa Shook Patient Name: Hannah Currin

Nutrition Assessment:
Client History:
22 y.o
Walking to class is the only exercise
Full-time student
Actively involved in her sorority
Has high school diploma, working toward bachelor degree
Majoring in finance
Caucasian
English speaking
Lives in a house with two other female roommates of similar age
Grandmother had type II DM
Food & Nutrition History:
During weekdays she eats something small before class or nothing at all.
Usually eats breakfast on the weekends
Frequently eats out with friends
Knows how to cook, but likes the convenience of eating out
Convenience of food plays a huge role due to busy/stressful schedule
Buys all of her own food
Fills up her large water bottle several times a day
Never drinks pop
Occasionally drinks alcohol on the weekends
Tends to over eat on the weekend since she has more time
Has taken no nutrition class
Has limited nutrition knowledge
7 out of 10 on readiness to change
Only a 7 because she is very stressed with school and doesnt know if she
has the time to exercise or put extra time into cooking for herself
Really wants to start living a healthier lifestyle and lose some weight
Typical Intake/d: 3097 kcals, 123g fat, 117g protein, and 52 fl oz
Anthropometrics:
CBW: 115#
IBW: 135#
% IBW: 114%
BMI: 28, Overweight

Biochemical/Tests/Procedures:
N/A
Nutrition Focused Physical Findings:
Good appetite
Good mood
Positive attitude
Comparative Standards:
Estimated kcals: -161+10(70.45)+6.25(170.18)-5(22)= 2135.3 x 1.3 x
1=2776 kcals/d
% kcals: 3097/2776=112%
Estimated protein: 70.45 x .8=56.36 g/d
% protein: 117/56.36= 208%
Estimated fat: 2776 x .30 = 832.8/9= 93g
% fat: 123/93 = 132%
Estimated fluid: 70.45 x 30 = 2113.5 cc/kg
% fluid: 1537.82/2113.5= 73%
Assessment Statement:
Ms. Currin is a 22 y.o women coming to the RD for assistance in
weight/lifestyle management. She is a college student with a stressful and
demanding schedule. Besides her walks to class Hannah lives a sedentary
lifestyle. Due to her busy schedule with school and her sorority, she
frequently eats out even though she does have the ability to cook. She
claims that it is more convenient for her to eat out and that it saves her time.
Her 3 day food record shows that her habit of eating out has caused her to
have excessive intake. On average she consumes 3097 kcal/d (112% estd
needs), 117g/d of protein (208% estd needs), 123g/d of fat (132% estd
needs), and 1538 fl oz/d (73% estd needs). This shows that the clients is
overeating and making poor food choices. This is also evidenced by the
clients weight. Hannah currently weighs 155# (28 BMI-overweight, 114%
IBW). When asked on her readiness to change, the client gave herself a 7 on
a scale of 1-10. She would really like to start living a healthier lifestyle, but
worries that her busy schedule will prevent her from being able to find
healthier food options. If she does not change her ways, her family history
(grandmother, type II DM) and her high kcal, protein, and fat diet indicate a
strong possibility of the development of diabetes and other nutritional
problems. To help with this lifestyle change, the client could greatly benefit
from some cooking education (how to make quick healthy foods) and some
basic nutrition education (myplate/reading labels). Then with some basic
nutrition knowledge, the client could use some instruction on a nutrition

tracking app, such a myfitnesspal, so that she can monitor her own progress.
Finally, the client should find a way to work some exercise into her life.

Nutrition Diagnosis/Goals:
Diagnosis 1: Excessive energy intake related to knowledge deficit as
evidenced by frequent eating out, consumption of 112% of estd kcals/d, and
weight of 114% of IBW.
Nutrition Interventions:
Nutrition Rx: 2776 kcals/d, general healthy diet
Nutrition Education:
-Purpose:
Improve nutrition quality of life and nutrition knowledge
-Relationship to disease
If lifestyle does not change then there is a strong chance of the development
of DM, HTN, or CVD. Type II DM is already present in family (grandmother).
-Modifications:
- Increase activity (with dr. approval)
- Education on portion control
- Education on reading labels
- Education on healthier food options
- Pack lunches/cook at home
- Limit the times eaten out on a weekly basis
-Application:
- Myplate
- Food Label
- Food Record
- Activity Log
- Portion Sizes
- Myfitnesspal tracking app
Counseling Techniques:
Goal Setting
- This will help the client move towards a healthier lifestyle by giving
them opportunities to work towards.
Motivational Interviewing

-This technique will give the client more confidence to accomplish their
goals
Health Belief Model
- This model will help to understand what the client is feeling. For
example if there are any barriers that need to be addressed or why they
think that the goals that were set will work for them.
Referral of Care:
-Approval by a doctor to begin exercise.
Goals:
1.Limit eating out to no more than 3 times a week.
2.Complete 30 minutes of moderate-vigorous exercise 3 days a week.
3.Decrese kcal intake to 2800kcal/d by next week.
4.Lose 1-3 pounds in one week.

Monitoring and Evaluation:

(Criteria/ Parameter)
-Monitor food record for kcal intake, goal is to be equal to or slightly less than
2800kcals.
-Monitor activity log, goal is to exercise 3 times a week for at least 30
minutes.
-Monitor eating out using the food record, goal is to eat out no more than 3
times a week.
-Monitor weight, goal is to lose 1-3 pounds in one week. (currently weighs
155 pounds)