Sage Dietetic Internship OUTPATIENT NCP Form

Patient Name: Patient 1

Reason for Nutrition Referral: Weight Loss Recommendation by

Doctor

DOB: 4/1/1974

NUTRITION ASSESSMENT
Food and Nutrition Related History:
Pt reports weight fluctuations related to childbirth and trying various diets throughout past 20 years with limited
adherence. Pt consumes peanut butter & jelly on white bread and fruit for lunch, and dinner consists of a protein,
starch, and salad topped with ranch dressing. Pt consumes snacks and dessert of a donut, cookies, ice
cream/pudding/Jell-O, and chips and dip. Coffee drink, 2% milk, cola, water, and juice consumed throughout the day.
Diet analysis software estimates daily kcal consumption of 2800. Pt takes one-a-day multivitamin.

Physical Assessment:
Well-nourished
Pt reports low energy
Anthropometric Measurements
Age:
Gender

Ht:

Current Wt: 80.9 kg

Admit Wt: 80.9 kg
41
F
167.64 cm
IBW: 59.1 kg
Wt Hx (specify time frame):
20 years
% Wt change: 21%
UBW: 63.63 kg
Biomedical Data (list only pertinent nutrition-related labs)
Labs
Date
HDL
Triglycerid
es
9/1/15
38 mg/dL
189
mg/dL
PMH:
Not applicable
Pertinent Medications & Dosage
None
Estimated Nutritional Needs based on
80.9
kg
Calories (kcal/kg & total kcal/day)
Protein (g/kg & total g/day)
23.9-30 kcal/kg = 1941-2427 kcal/day
1g/kg = 80.9g/day

BMI:
28.79
BMI Classification:
Overweight

Fluid (ml/kg & total ml/day)

30-35 ml/kg = 2427-2831.5 ml/day

NUTRITION DIAGNOSIS (include IDNT codes)

P (problem) NI-2.2 Excessive Oral
Intake related to:

E (Etiology) food and nutrition related

knowledge deficit concerning
appropriate oral food/beverage
intake as evidenced by:

P (problem) NI-5.6.2 Excessive Fat

Intake related to:

E (Etiology) food and nutrition related

knowledge deficit concerning
appropriate amount of dietary fat as
evidenced by:

S (Signs & Symptoms) 21% weight

gain in 20 years, pt reported intake of
high caloric-density food/beverages
(coffee-drinks, donuts, cookies, ice
cream, soda, juice), estimated intake
exceeding estimated needs by 40%,
BMI of 28.79 indicating pt is
overweight.
S (Signs & Symptoms) HDL
cholesterol less than 50 mg/dL
(38mg/dL), triglycerides greater than
150 mg/dL (189 mg/dL), fat intake
42% total energy intake, frequent
portions of high-fat foods (donuts,
cookies, ice cream).

INTERVENTION
Educate patient on appropriate food choices to provide 2300 kcal per day (a 500kcal deficit from usual intake) to
facilitate weight loss. Give patient examples of nutrient-dense foods to choose over the caloric-dense, high-fat foods
that she typically consumes.
See patient back in 4 weeks for follow-up to measure progress and reassess energy needs based on weight-loss.

2014

SGS DI

MONITORING & EVALUATION

Indicators (marker):
Weight
Reported food/beverage intake
Estimated energy intake

Criteria (SMART Goal specific to marker):

1. Pt will lose 1.8 kg before next follow-up appointment.
2. Patient will report intake of 1 or less caloric-dense
food/beverage per day.
Daily food journal entries will reflect daily energy intake
of 2300kcal (+/- 100kcal)

Ashley M Prendergast

9/6/2015

______________________________________________________________________________________
Interns Signature
Date

2014

Date

Preceptors Signature

SGS DI