Patient: W.

Referred

for: LTQnnual review

Food and Nutrition Related History: Resident eats 3 meals per day and an HS snack -breakfast usually toast with butter, Lactaid, apple juice, banana -lunch usually includes a tossed salad with ltalian dressing, apple juice, Lactaid, along with main course -supper usually includes rye bread, tossed salad with low fat dressing, apple juice, Lactaid along with main course Resident uses a Kennedy cup to assist with self-feeding Resident has76-L0O% of each meal and has 350-480 mL fluids with each meal Resident does not like prunes or prune juice Resident's mother often brings in meals that she states are low in sodium Resident in wheel chair with very limited physical activity

Anthropometric Measurements
Age: 66 yo

Gender: M

Ht:70" (178 cm)

Wt:281# (727kel
Wt Hx: stable since last year % Wt chanee:

BMI:40.3 (obese)

Biomedical Data, Medical Tests & Procedures Labs/Date I Albumin I Glucose HbAIC

BUN

Creat

Na+

K+

Hgb

Hct

MCV

Other

I/8/74
H/O DVT

113me/dl

35ms/dL

1.0ms/dL

L44mEq/L I 4.6mEq/L

Medical Diagnosis/PMH/Relevant Conditions:

Seizure disorder, hypothyroidism, bilateral lower extremity paraplegia, venous insufficiency, GERD, occasional constipation managed with meds

Pertinent Medications: Lasix, Synthroid, vit. D, folic acid, thiamine, Os-cal, MVl,
Skin

KCL,

Miralax PRN

status:

X lntact n

Pressure Ulcer/Non-healing wound; Comments:

Estimated Nutritional Needs Based on Comparative Standards: Protein: .8-7e/ke 2030-2540kcal/ke 702-!27cldav Diet Order: Feeding Ability Consistent CHO tr lndependent Heart Healthy Diet X Limited Assistance
Calories: 16-20kcal/kg

Fluid: 25-30m1/kg 3175-3810m1/day

Oral Problems

nta ke

Chewing Problem

Good l>75%\

! 0 tr
P

Extensive/Total Assistance
N/A

tr Swallowing Problem tr Mouth Pain X None oftheAbove

f] Fair (approx. 50%) tr Poor (<50%) I Minimal-(<25%) tr NPO

No Nutritional Diagnosis at this

time

Proceed

to Nutritlon Diaenosis Below

S (Signs

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

(Etiology): limited ability for physical activity

& Symptoms): BMI of 40.3 (obese)

as evidenced bv:

Nutrition Prescription:
Continue on Heart Healthy and Consistent CHO diet 2030-2540kcalldav,702-t27e pro/dav, 3175-3810m1 fluid/dav, 1.5-2e NA/dav, < 20s saturated fat, 285s CHO (71e Der meal) Food or Nutrient Delivery: Nutrition education: Meals and snacks (ND -1.0) None at this time Nutrition Counseling: Coordination of Care (refer to): None at this time Recreational therapist for incorporation of phvsical activiW
Goal(s): Resident

wt. not to exceed 281#

Criteria:

lndicators:

Monitor wt. monthly Monitor intake and physical activity

wt.

< 281#

",,,%"u
.n
Date
5

lntern's Signature

'Jglt
SGS DI

2013