Sage Dietetic Internship Inpatient NCP Form

Patient Name: N. J.
Admit Date: 1/22/16

Current Date: 3/30/16

Reason for Nutrition Consult: Quarterly Assessment

Admit Medical Diagnosis: Difficulty Walking/Knee Pain

NUTRITION ASSESSMENT
Food and Nutrition Related History:
Regularly consumes 76-100% of all meals served. Prefers to eat most meals in her room but knows the option to eat
her meals in the dining room is available at all times.
Constipation reported in the beginning of the month. Resident thinks it could be due to the fentanyl Senna and
MiraLax were initiated 3/7/16 for constipation tx. BMs have been every day since initiation of medications.
Resident reports following a low-sodium diet at home prior to admission to the hospital and LTC facility
N. J. is not happy with her weight. She was told if she loses weight her family will bring her back home. She is ready for
diet-lifestyle change and has been compliant with DASH/TLC diet RX. She does not over order on the menu options.
3/8/16 Resident had a choking incident. Diet downgraded from regular consistency to ground in response. SLP Eval
3/10/16 found no chewing/swallowing problems. Diet was upgraded back to regular textures 3/14/16 to the residents
liking. No further issues noted, reported, or observed.
Current Inpatient Diet
Feeding Ability
Oral Problems
Order:
X Independent
Chewing Problem
Limited Assistance
Swallowing Problem
DASH Diet

Extensive/Total
Assistance
Mouth Pain
TLC Diet

N/A
X None of the Above
Thin Liquids
Explain: Set-up help only (tray
delivery, removal of tray lid)
Physical Assessment:
Obese elderly female, alert and orientated x 3. Dentition natural, in good condition. Uses wheelchair to ambulate, up
with 2-assist.
Anthropometric Measurements
Age:
Gender
Ht:
Current Wt: 314.6#
BMI:
76
Female
65
Admit Wt: 317.9#
52
IBW: 132-162#
ABW: 199#
BMI Classification:
UBW: 300s, unable to obtain
Obese Class III
specific
Wt Hx (specify time frame): 2
months
% Wt change: 1% decrease in
weight
Biomedical Data (list only pertinent nutrition-related labs)
Labs

Date
No
New
Labs
Inpatient Medical Course Relevant to Nutrition (i.e. surgeries, procedures, tests, I/O, etc.):
S/P knee pain with decreased ambulation receiving PT for strengthening to return home. Food and beverage intake
recorded. BMs recorded TID. Weights recorded once per month.
PMH:
Depression, Heart Disease, HTN, arthritis, anxiety
Pertinent Medications & Dosage
Diazepram, fentanyl, MiraLax, senna, omega-3 FA, red yeast rice
Skin status:
X Intact Pressure Ulcer/Non-healing wound; Braden Score (only when skin is intact): 15
Comments: Redness in groin area noted on skin assessment 3/29/16
Estimated Nutritional Needs based on 143 kg
Calories (kcal/kg & total kcal/day)
20-25 kcal/kg & 1800-2250 kcal/day
(ABW)

Protein (g/kg & total g/day)

0.8-1 g/kg ABW & 72-90 g/day

Fluid (ml/kg & total ml/day)

20-25 ml/kg & 1800-2250 ml/day
(ABW)

NUTRITION DIAGNOSIS (include IDNT codes)

2014

SGS DI

P (problem)
Obesity related to:

E (Etiology)
physical inactivity as evidenced by:

S (Signs & Symptoms)

BMI 52 (Obesity Class III), inability to
ambulate independently due to knee
pain.

INTERVENTION
Continue to offer nutrition/diet education with follow-ups and at meal rounds.

MONITORING & EVALUATION

Indicators (marker):
Weight
Intake Menu Choices

Criteria (SMART Goal specific to marker):

Resident will weigh between 298-314 by next follow-up
Resident will continue to choose less than 3 concentrated
sweetened desserts per week and continue to refuse
candies/snacks brought in by family.

_______________________________________________________________________________________________
Interns Signature
Date

Date

Preceptors Signature

RATIONALE (required section):

1. Discuss reasons for including each abnormal lab:
No new labs available.

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

equations & references used):
To calculate needs, I used her adjusted body weight at 20-25 kcal/kg and the
Mifflin St Jeor equation for confirmation. Both methods returned with similar
results, 1800-2300. Because this woman is classified as Obese Class III, she
needs to lose a good amount of weight to be able to be as mobile as she was
before the severe weight gain. With her desire to lose weight so she can
return home, she is motivated to get the weight off. Although she has been
cutting back she reports not losing any weight due to a decrease in
metabolism. For someone who has such a high weight, the calorie estimation
seemed extremely low at first. After talking to the resident, she is satisfied
with this amount of calories. She can only ambulate in a wheelchair and needs
two-assist to get up. Her activity level is low and her physical therapy
treatments are mild at this point. Because of these reasons, she does not need
more than 2000 kcal/day.

2014

SGS DI