Sage Dietetic Internship - NCP Fornn
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Sage Dietetic Internship - NCP Fornn JM Referred foi Nutrition assessment and education related to Type II diabetes and subsequent renal disease Food and Nutrition Related Hlstoiy: 24-hour recall: Breakfast- omelet with 2 eggs Slice of white toast Coffee Lunch: Steak sand which on 2 slices white bread Plum Dinner: 6 oz steak 1 baked potato Steamed broccoli Apple crisp Snack: yogurt Anthropometric Measurements Age: 7S Gender Male Ht: 6'3- Wt: 131 kg WtHx: % Wt change: dryj, 288 lb BMI: 35.7, obese Biomedical Data, Medical Tests & Procedures Labs/Date Albumin Glucose HbAlC BUN Creat N8+ Kt Hgb Hct MCV Other 9/8/2013 3.7 g/dL n/a n/a n/a 6.2 mg/d n/a 4.0 mEq/L 10.3 30.1 n/a n/a Medical Diagnosis/PMH/Relevant Conditions: Type II diabetes ^--'^Chro^ic kidney disease Vnemia HTN Apnea Pertinent Medications Phos Lo Calcium acetate Folic acid Humalog Lantus Omeprazole Sensapar Warfarin Crestor Metroporol Skin status: O Intact X • Pressure Ulcer/Non-heallng wound; Comments; S/P amputation R toe Physical Assessment! Estimated Nutritional Needs Based on Comparative Standards: using id ;al BW = ZO0 Ib,90j<g Calories 2,700-3,000 kcal/day (25-35 kcal/kg) Protein 99 g /day l.lg/kg (non-healing Fluid 2700-3000 ml/day (25-35 mU/kg) Diet Order Diabetic diet Feeding Ability XD Independent • Limited Assistance a Extensive/Total Assistance • N/A Oral Problems a Chewing Problem • Swallowing Problem • Mouth Pain Xn None of the Above intake XD Good (> 75%) • Fair (approx. 50%) a Poor(<5094) • Minimal-(<25%) O NPO 2013 SGSDI I 'd mm mil
Transcript of Sage Dietetic Internship - NCP Fornn
Sage Dietetic Internship - NCP Fornn
JM Referred foi Nutrition assessment and education related to Type II diabetes and subsequent renal disease
Food and Nutrition Related Hlstoiy:
24-hour recall: Breakfast- omelet with 2 eggs
Slice of white toast Coffee
Lunch: Steak sand which on 2 slices white bread Plum
Dinner: 6 oz steak 1 baked potato Steamed broccoli Apple crisp
Snack: yogurt
Anthropometric Measurements Age: 7S
Gender Male
Ht: 6 ' 3 -
Wt: 131 kg WtHx: % Wt change:
dryj, 288 lb BMI: 35.7, obese
Biomedical Data, Medical Tests & Procedures Labs/Date Albumin Glucose HbAlC BUN Creat N8+ Kt Hgb Hct MCV Other 9/8/2013 3.7 g/dL n/a n/a n/a 6.2 mg/d n/a 4.0
mEq/L 10.3 30.1 n/a n/a
Medical Diagnosis/PMH/Relevant Conditions: Type II diabetes
^--'^Chro^ic kidney disease Vnemia HTN Apnea
Pertinent Medications Phos Lo Calcium acetate Folic acid Humalog Lantus Omeprazole Sensapar Warfarin Crestor Metroporol Skin status: O Intact X • Pressure Ulcer/Non-heallng wound; Comments; S/P amputation R toe
Physical Assessment! Estimated Nutritional Needs Based on Comparative Standards: using id ;al BW = ZO0 Ib,90j<g
Calories 2,700-3,000 kcal/day (25-35 kcal/kg) Protein 99 g /day l . lg/kg (non-healing
Fluid 2700-3000 ml/day (25-35 mU/kg)
Diet Order Diabetic diet
Feeding Ability XD Independent • Limited Assistance a Extensive/Total Assistance
• N/A
Oral Problems a Chewing Problem • Swallowing Problem • Mouth Pain Xn None of the Above
intake XD Good (> 75%) • Fair (approx. 50%) a Poor(<5094) • Minimal-(<25%) O NPO
2013 SGSDI
I 'd mm mil
J No Nutritional Diagnosis 9t this time X D Proceed to Nutrition iagnosis Below
- ^ P (problem) Increased nutrient needs ••[protein) NI-5.1
related to:
P (problem). related to:
E (Etiology) inc( protein due to wound healing
eased demand for 5 (Signs a Symptoms) Delayed wound healing
_8s evidenced by: E (Etiology). S (Signs & Symptoms)
_as evidenced by:
Nutrition Prescription: Add Nepro supplement 1 x daily
Food or Nutrient Delivery; Oral
Nutrition education: n/a at this time
Nutrition Counseling: n/a at this time
Coordination of Care (refer to): n/a at this time
Goal(5): Aid in wound healing process through adequate protein intake
Indicators: Wound has healed
Criteria: no worsening of wound Skin closure on wound
ftceptor's Signature y f ^ Date _09/09/2013_
intern's Srenature Date 1 7
2013 SG5 Dl
i 'd mm ma-^i no^ 'oi m
