Академический Документы
Профессиональный Документы
Культура Документы
Client
Name:
DC
Age:
56
Appointment
length:
60
minutes
Client
History
Reason
for
visit/HPI:
Referred
by
MD
for
nutritional
education
for
stage
4
colon
CA
support.
Willing
to
do
whatever
she
can
to
fight
CA,
get
healthy,
and
lose
weight.
PMH:
Surgical
resection
of
tumor
6w
ago
with
6
of
transverse
colon
and
small
wedge
portion
of
liver
removedpt
healed
and
normal
eating
resumed.
Started
chemo
tx
2
wks
ago
and
will
continue
q
other
wk
for
next
6m-1yr
at
least.
Mild
s/s
so
far.
Has
hx
of
hypothyroidism,
HTN,
and
hypercholesterolemia.
Family
Med
Hx:
Pts
father
and
grandfather
died
of
colon
CA.
Pts
mother
had
HTN
and
died
of
MI.
Environmental
and
Medication
Allergies:
NKA
Tobacco
/
Drug
use:
n/a
RX/OTC:
fluorouracil,
oxaliplatin,
avastin,
prilosec,
lisinopril,
levothyroxine,
simvastatin,
MVI
Doctors
Choice
for
Women
(Enzymatic
Therapy),
Vitamin
E
400
IU
Physical
activity:
Little
PA
in
past;
generally
busy.
Doesnt
enjoy
sitting
around,
but
dislikes
gym.
Walked
2x
this
wk
for
almost
1mi.
Just
got
a
dog
to
help
motivate
her
to
walk
outside
more
often.
Social
Hx:
Married
to
supportive
husband.
Critical
care
nurse
for
20
yrs.
Used
to
being
busy,
reports
difficulty
slowing
down.
Self-reported
Type
A.
Positive
outlook,
family
is
worried.
Other
client
hx
notes:
n/a
Food
and
Nutrition
History
24
hour
recall/
Typical
day:
B:
8
oz
black
tea,
c
FF
Fage
Greek
yogurt,
c
honey
nut
cheerios,
c
FF
milk.
L:
6
Subway
club,
12
oz
iced
tea
with
lemon.
D:
10
oz
Stouffers
cheese
lasagna,
8
oz
water.
Doesnt
eat
past
7:30
pm.
Nutrition
Intake
Analysis
Results
-
ESHA:
Deficient
in
most
nutrients:
Energy
832
kcal
(43%);
Protein
58
g
(88%);
Fiber
10.5
(50%);
Fluids
564
mL
(24%);
vitamin
A
(22%);
vitamin
C
(34%);
folate
(54%);
vitamin
K
(0.5%);
Ca
(74%);
w-3
FA
(1.8%).
Caffeine
2,000
mg.
Food
and
Nutrition
History:
Enjoys
cooking,
willing
to
try
new
recipes.
Dietary
preferences:
Likes
most
foods,
nothing
I
wont
eat.
Food
allergies
/
intolerances:
NKA
ETOH:
Drinks
wine
2-3x/wk.
Weight
History:
Skinny
in
20s,
early
30s.
Gained
wt
mid
30s.
Highest
wt
(185
lbs)
when
dx
with
CA.
Meals
away
from
home:
Eats
out
2-3x/wk.
Restaurant
Type:
Greek,
Thai
Who
prepares
food:
Pt
cooks,
friends
&
family
willing
to
help.
Where
shops
for
food:
QFC,
TJs,
sometimes
PCC
Other
nutrition
notes:
Financially
secure
Physical
Findings
GI
Function:
Loose
BMs
4x/day,
stomatitis
Sleep
hx:
7-8
hrs/nt
Energy
level:
2.5/5.
Feels
tired
and
weak
often.
Pt
appears
to
have
high
energy
during
apt.
Stress
level:
3.5/5.
Overall
clinic
observation:
Pt
speaks
quickly,
laughs
easily,
has
high
energy.
Highly
motivated.
Biochemical
Data
(Pertinent
Labs):
Sodium
135
mEq/L
(low);
BUN
28
mg/dL
(high);
GFR
78
mL/min
(low);
HCT
29.5%
(low);
Hgb
9.6
g/dl
(low);
TC
215
mg/dl
(borderline
high);
LDLc
129
mg/dl
(above
optimal);
all
other
labs
WNL.
Anthropometrics
Height:
64
(162.56
cm)
Weight:
178
lbs
(80.91
kg)
BMI:
30.6
(Obese)
Ideal
weight
(Hamwi):
120
lbs
(108-132
lbs)
%ideal
weight:
148%
Usual
weight:
185
lbs
%usual
weight:
96.2%
%
Wt
change:
4%
decrease
in
6
wks.
Weight
change
classification:
of
concernmonitor
throughout
tx
Desired
weight:
n/a;
pt
expresses
desire
to
lose
wt.
Adjusted
BW:
132
lbs
(60
kg);
Upper
end
of
IBW
range
Estimated
Needs
/
Nutrition
Prescription
REE/
Kcals:
Mifflin
St.
Jeor:
1,388
kcal
REE
REE
x
AF
(1.1
-
1.2;
obese)
x
IF
(1.3
-
1.4;
cancer)
=
2,000-2,165
kcal
Protein
(g/kg):
60-72
g
Adj.
BW
(kg)
*
1.2-1.4
g/kg
=
72-84
g
Fluids
(ml/kg):
2.4
L/d
BSA
(M2)
=
[the
square
root
of
(Wt
(kg)
x
Ht
(cm)]
60
=
[the
square
root
of
(60
kg
x
162.56
cm)]
60
=
1.646
BSA
x
1500
=
ml
fluid
needs
1.646
x
1500
=
2,469
ml;
2.4L
Fiber
(g/day):
<10
g/d
(Low
Residue)
Other:
n/a
Nutrition
Diagnosis
Problem:
Undesirable
food
choices
(NB-1.7)
Etiology:
Food
and
nutrition-related
knowledge
deficit
of
how
to
support
GI
health
during
chemotherapy
tx
to
alleviate
diarrhea
Signs
and
Symptoms:
referral
from
doctor,
typical
intake
reflects
consumption
of
potential
gut
irritants
(caffeine,
dairy,
occ
ETOH),
and
loose
stool
up
to
4x/day.
Problem:
Inadequate
fluid
intake
(NI-3.1)
Etiology:
knowledge
deficit
about
appropriate
fluid
intake
for
chemo
tx
Signs
and
Symptoms:
typical
intake
23.5%
of
calculated
fluid
needs
per
BSA
calculation