Sage Dietetic Internship Inpatient NCP Form

Patient Name: P.L.

Admit Date:

Current Date:
12/10/15

Reason for Nutrition Consult: Quarterly Nutrition Assessment

Admit Medical Diagnosis: COPD

NUTRITION ASSESSMENT
Food and Nutrition Related History:
Resident has COPD and SOB. HX of decreased appetite/interest in food R/T dementia and depression. Resident
frequently reports disliking meals and often accepts alternates (e.g. grilled cheese). Reports strong preference for fresh
fruits but feels the fruit cocktails are not fresh. Resident receives Ensure Plus supplement 240 mL 1x/day at HS
snack. Resident maintains low body weight with no significant change over past year.
Current Inpatient Diet
Order:
Regular; thin liquids

Feeding Ability
Independent
Limited Assistance
Extensive/Total Assistance

N/A

Explain:
Resident feeds herself
independently with mainly no set
up help reported by nursing
staff. Resident eats in her room
as per preference of quiet
environment.

Oral Problems
Chewing Problem
Swallowing Problem
Mouth Pain
None of the Above
Explain:
Resident reports no difficulty
chewing/swallowing as evidenced by
regular diet RX. Resident has partial upper
dentures.

Physical Assessment:
Resident is alert and oriented x3. Resident is ambulatory and able to make needs known. Skin is intact.
Anthropometric Measurements
Age:
Gender
Ht:

Current Wt: 101# (12/9/15)

Admit Wt: N/A
76
Female
64
IBW:126-154#
Wt Hx (specify time frame):
30 day: 101#
(11/4/15)
90 day: 99 # (9/2/15)
180 day: 100#
(6/3/15)
% Wt change: No significant
change
Biomedical Data (list only pertinent nutrition-related labs)
Labs

Date
NO NEW LABS SINCE 1/20/2015

BMI:
17.3
BMI Classification:
Underweight

Inpatient Medical Course Relevant to Nutrition (i.e. surgeries, procedures, tests, I/O, etc.):
Resident has COPD with HX of heart disease, dementia, anxiety, depression, HTN, and osteoporosis. Resident is O2
dependent with SOB R/T COPD.
PMH:
Resident has COPD with HX of heart disease, dementia, anxiety, depression, HTN, and osteoporosis.
Pertinent Medications & Dosage
Ativan, Cardizem, Fosamax, Mirtazapine, Senna, Multivitamin, Vitamin C, Vitamin D3
Skin status:
Intact Pressure Ulcer/Non-healing wound; Braden Score (only when skin is intact): _______________
Comments:

Skin assessment on 12/7/15 reported intact.

Estimated Nutritional Needs based on 46 kg
Calories (kcal/kg & total kcal/day)
Protein (g/kg & total g/day)
1,377-1,607 kcal (30-35 kcal/kg)
46g (1.0 g/kg)

Fluid (ml/kg & total ml/day)

1,377 mL (30 mL/kg)

NUTRITION DIAGNOSIS (include IDNT codes)

2014

SGS DI

No new nutrition DX/PES at this time, plan is for maintenance. Resident maintains low body weight
without significant change. Skin remains intact; no new labs since 1/20/2015. Resident continues
Remeron which may aid in stimulating appetite, as well as receives multivitamins, vitamin C and vitamin
D3 supplements. Food/supplement/fluid intakes appear adequate to meet nutrient needs as evidenced by
stable wt. and estimated average intakes of 51-75%. Resident often accepts meal alternates (e.g. grilled
cheese) and daily selective menu continues. Preferences reviewed and updated with resident. No N/V/C/D
as evidenced by regularly noted BMs and resident reports. Regular diet RX and Ensure supplement
appropriate to provide least restriction and aid in meeting energy/nutrient needs. Suggest change to
evening snack and timing of Ensure supplement per resident request. Resident has met intake and
weight goals made during last review. Continue plan of care and low risk.

INTERVENTION
Continue plan of care:
Intakes will continue to meet estimated needs by next review
Weight will remain at or above 98# by next review
Nutrition recommendation: suggest change delivery time of Ensure Plus from evening snack to
lunch
Assist with oral intake as needed: set up help
Meet food preferences as able and offer available alternatives if resident is not satisfied with
meal; offer snacks between meals if needed
Monitor and encourage intake of food, fluid, supplement, and snack during meal rounds and with
nutrition follow-up; offer fluids between meals and with medication pass
Monitor nutrition-related lab work as available with follow-up for review
Monitor weight as required for significant change and to meet established goal
Provide medically appropriate diet: regular
Provide nutrition education as needed with meal rounds and follow-up: importance of adequate
intakes to prevent weight loss/malnutrition
Provide snack per resident preference: evening daily
Provide supplement per MD order: 240 mL Ensure Plus once daily
Risk level: low

MONITORING & EVALUATION

Indicators (marker):
Estimated average intakes
Weight

Criteria (SMART Goal specific to marker):

51-75%= adequate intake
At or above 98#

_______________________________________________________________________________________________
Interns Signature
Date

Date

Preceptors Signature

RATIONALE (required section):

1. Discuss reasons for including each abnormal lab:
-

No new labs since 1/20/15

2. Discuss justification for choosing method of calculating needs (specify

equations & references used):
-

2014

30-35 kcal/kg: resident has COPD requiring increased energy needs.

1.0 g/kg: resident has no HX/current pressure ulcers requiring increased protein
needs.
30 mL/kg: resident has no HX of CHF/CKD/edema/hyponatremia.

SGS DI