FDNT 452: Medical Nutrition Therapy II Name: Brandon Harper

Lab #3: Heart Failure

Please type the lab report and submit via Dropbox in Learning Hub Total Points: _____ / 28
Due: February 1, 2019

Case 6 – Heart Failure with Resulting Cardiac Cachexia

Complete the following questions based on Mrs. Maney’s case:

I. Understanding the Disease and Pathophysiology

1. Outline the typical pathophysiology of heart failure. Onset of heart failure usually can be
traced to damage from an MI and atherosclerosis. Is this consistent with Mrs. Maney's
history? (2 pts)

HF happens due to cardiac remodeling, this occurs based on the stress put on the heart and the
compensatory mechanisms that try to restore its ideal balance. The compensatory mechanisms
include, cytokines and BNP. The increased stress on the heart usually results in fluid retention,
shortness of breath, fatigue, memory loss, anxiety, syncope and dry cough. The main HF symptoms
that contribute to malnutrition include anorexia, abdominal pain, nausea, constipation and
malabsorption. Mrs. Maney exhibits edema, ascites, decreased renal perfusion and has medical
history of CAD, HTN and mitral valve insufficiency with previous anterior MI, so her history is
consistent with HF.

2. Identify specific signs and symptoms in the patient’s physical examination that are consistent
with heart failure. What are the hallmarks of HF and does Mrs. Haney display any of these
symptoms? (2 pts)

Signs and symptoms consistent with heart failure: low blood pressure 90/70, 110BPM, temporal wasting,
pedal edema, ascites, liver tenderness and jugular venous distention. Liver tenderness – shows
inadequate blood supply to abdominal organ. Pedal edema- caused by retention of fluid. Temporal
wasting- adiponectin (proinflammatory cytokine) levels serve as marker for wasting.

II. Understanding the Nutrition Therapy

3. Mrs. Maney’s husband states that they have monitored their salt intake for several years. What
is the role of sodium restriction in the treatment of heart failure? What level of sodium
restriction is recommended for a patient with heart failure? What difficulties may a patient
have in following a sodium restriction? (2 pts)

For patients with heart failure it is very important that sodium is restricted because high amounts of
sodium in the body lead to high levels of water retention. Patients with heart failure are recommended
to limit themselves to 2-3g of sodium unless there are severe symptoms. Symptoms like edema could
impact these recommendations along with the stage of heart failure the patient is in.

About patients obeying sodium levels a big detail is their cultural backgrounds. Some cultures rely
heavily on salt and therefore makes it very difficult for patients to adhere to the recommended levels.
Another possible cause for the lack of adherence is that the patients do not know about how much
sodium certain foods have and which foods are low in sodium. This lack of knowledge also applies to
food labels. Most people find it difficult to read labels and as a result do not know how much sodium
they consume.

1
(Lack of cooking skills is also a reason because then they rely heavily on premade food; food labels)

4. Why is Mrs. Maney placed on fluid restriction? How will this assist with the treatment of her
heart failure? What specific foods are typically contribute fluid intake? (2 pts)

Mrs. Maney is being placed on fluid restriction because she has edema, this will help her lab values, this
helps relieve symptoms of the heart disfunction. Foods that count towards fluid intake include, juices,
milk, ice chips, soup, (liquids), fruits high in water.

III. Nutrition Assessment

Show work. This will be evaluated in the ADIME rubric.

5. Anthropometrics:
Calculate the following and interpret the significance of this assessment

a) BMI
47.7kg/(1.57m2) = 19.35 Normal

b) % Weight Change
This cannot be determined with the information provided

c) UBW
The patient’s usual body weight is not provided

d) % UBW
Because the patient UBW is not provided the percent of UBW cannot be calculate either

e) IBW
5’2 = 62in
100 + 10 = 110lbs

f) % IBW
105 lbs/110lbs =0.9545 x 100 = 95.5%

6. Calculate Mrs. Maney’s energy and protein requirements. Explain your rationale for the weight
you have used in your calculation.

Because the patient is experiencing edema, the current weight cannot be used to calculate energy
requirements. For this reason, IBW will be used instead,

30-35kcals per kg

30kcals x 50 = 1,500

35kcals x 50 = 1,750

Protein:

47.7kg x 1.2g = 57.24 = 57g

47.7kg x 1.4g = 66.78 = 67g

2
7. Do you have any evidence that Mrs. Maney may be malnourished? Identify factors that may
support a diagnosis of malnutrition using the latest AND/ASPEN proposed guidelines for
malnutrition diagnosis. (1 pt)

Mrs. Maney displays more than 2 characteristics of malnutrition and is therefore said to be
malnourished. The patient reports having a poor appetite over the last six months which is the first
red flag. The next cause of concern that support the diagnosis of malnutrition is her weak hand grip.
By simply possessing these two characteristics it can be determined that malnutrition is taking place,
but the patient displays more symptoms; she has temporal wasting and edema in her extremities.
Because of all of the characteristics of malnutrition, it is of upmost importance to address this so that
the cardiac muscle is not compromised.

8. Malnutrition in heart failure is often referred to as cardiac cachexia. What is cardiac cachexia?
What are the characteristic symptoms? Explain the role of the underlying heart disease in the
development of malnutrition. (2 pts)

Cardiac cachexia is basically the result of heart failure. At this point, patients are experiencing
involuntary weight loss of “at least 6% of non-edematous of body weight” over six months. During
cardiac cachexia, the body is losing lean body mass in high quantities which includes cardiac muscle.
As the hearts muscle becomes soft and flabby, heart failure is further encouraged to continue.

The symptoms of cardiac cachexia include: inadequate blood supply to the abdominal organs,
anorexia, nausea, feeling full, constipation, abdominal pain, malabsorption, hepatomegaly, and liver
tenderness. All of this in turn promotes malnutrition because the there is not enough blood flow to the
gut and results in the integrity of the bowel being lost. This allows bacteria and endotoxins to enter
the bloodstream and cause cytokine activation. Some cytokines that are activated like TNF-alpha and
adiponectin are associated with lower BMI, smaller skinfold measurements, and decreased protein
levels in the plasma. Finally, due to the muscle wasting that this process sets in action directly affect
the patient’s mortality.

9. Identify any abnormal biochemical values associated with Mrs. Maney's heart failure or CVD
and assess them using the following table: (3 pts)

Name of Normal Patient’s Value & Reason for Abnormality

Laboratory Value Date
Value
Sodium (mEq/L) 136-145 2/14: 132mEq/L Too much fluid
2/16: 133mEqL
2/20: 135mEqL
BUN (mg/dL) 6-20 2/14: 32mg/dL Decreased Kidney function and decreased
2/16: 34mg/dL
renal blood flow
2/20: 30mg/dL
Creatinine serum 0.6-1.1 2/14: 1.6mg/dL Decreased Kidney function and decreased
2/16: 1.7mg/dL
(mg/dL) renal blood flow
2/20: 1.5 mg/dL
Bilirubin, direct <0.3 2/14:1.0mg/dL Impaired liver function, increased hemolysis
2/16: 1.1mg/dL
(mg/dL)
2/20: 0.9mg/dL
Protein, total 6-7.8 2/14: 5.8g/dL Too much fluid
2/16: 5.6 g/dL
(g/dL)
2/20: 5.5g/dL

3
 Name of Normal Patient’s Value & Reason for Abnormality
Laboratory Value Date
Value
Albumin (g/dL) 3.5-5.5 2/14: 2.8g/dL Too much fluid, protein catabolism
2/16: 2.7g/dL
2/20: 2.6g/dL
Prealbumin 18-35 2/14: 15mg/dL Too much fluid, hepatomegaly
2/16: 11mg/dL
(mg/dL)
2/20: 10mg/dL
ALT (U/L) 4-36 2/14: 100 U/L Impaired liver function
2/16: 120 U/L
2/20: 115 U/L
AST (U/L) 0-35 2/14: 70 U/L Impaired liver function
2/16: 80 U/L
2/20: 85 U/L
CPK (U/L) 30-135 2/14: 180 U/L Impaired heart muscle, too much fluid
2/16: 200 U/L
2/20: 205 U/L
Troponin T (ng/L) <0.03 2/12: 0.035 Myocardial infarction
2/14: 0.037
2/20: 0.036
Troponin I (ng/L) < 0.2 2/12: 0.026 Myocardial infarction
2/14: 0.028
2/20: 0.027
HDL-C (mg/dL) >59 2/12: 30 Unhealthy dieat and lack of physical activity
2/14: 31
2/20: 30
LDL (mg/dL) <130 2/12: 180 Unhealthy diet and lack of physical activity
2/14: 160
2/20: 152
LDL/HDL ratio <3.22 2/12: 5.00 Unhealthy diet and lack of physical activity
2/14: 5.23
2/20: 4.97
WBC ( 103/mm3) 4.8-11.8 2/12: 12.7 Inflammation
2/14: 13.4
2/20: 10.5

10. The following drugs/supplements that were prescribed for Mrs. Maney. Give the medical
rationale for the use of each. In addition, describe any nutritional concerns for Mrs. Maney
while she is taking these medications. (2 pts)
Medication Rationale for Use Nutrition Implications

Lanoxin Lowers sodium inside heart Causes loss of appetite, nausea, vomiting, diarrhea which
cells which reduces the strain may not be helpful since the patient is malnourished and
on the heart need to retain nutrients

Lasix Is used to reduce edema and Lowers levels of potassium along with nausea and
reduce swelling by increasing vomiting which are detrimental for the patient since she is
urine output malnourished

Dopamine Forcefully helps the heart Advice against aged cheeses, aged meats, sauerkraut,
beta more as well as increase and alcohol
urine output

Thiamin Helps fuel myocardial Closely monitor thiamine diphosphate lab levels
contraction, urine output, and
improves signs and symptoms
of heart failure

4
IV. Nutrition Diagnosis
11. Select two nutrition problems using the NCPT. (2 pts)
1. Inadequate oral intake
2. Chronic Disease related malnutrition

12. Complete an ADIME note. (10 pts)

PES: Chronic disease related malnutrition related to heart failure as evidenced by displaying edema,
weak grip strength, loss of appetite, and muscle wasting.

5
Nutrition Assessment
HF and malnutrition HTN, CAD, mitral valve replacement
DX PMH___________________________________________________
105lbs
5’2’’ N/A 110lbs 95.5 %
Sex F Age 65 Wt Ht_______ABW IBW______________ % IBW_______
UBW___________%UBW_________%
N/A N/A Wt. Δ_____________BMI___________
N/A 19.3 normal

Labs Glu 102-110 Bun 30-34 Cr 1.5-1.7 Na 132-135 K+ 3.6-3.8 Chol 149-162 TG 78-82 Alb_______
2.6-2.8

4.9
Hgb 10.1-10.7 Hct 29-31 A1c Others(s) ______________________________________________
Lanoxin, Lasix, Aldactone, Listeninopril, Lopressor, Zocor, Metamucil, Calcium, Carbonate, Centrum
Pertinent Medications ____________________________________________________________________________

NFPA:
edema
GI: N V D C Dentition Skin Condition Vital Signs T_____BP____
X 90/70

Current Diet Order/regimen Food Intake_________________________

X
Fat/Muscle Loss _____________________________________________Edema:
temporal wasting none +1____+2_____+3_________

Micronutrient Exam: N/A

___________________________________________________________________________
Estimated nutrition Needs:
______________________
1,500 - 1,750 kcal/day based on 30 - 35 kcals/kg
__________________________________________________________
______________________protein/day
57-67 based on_____________
1.2 - 1.4 g/kg)
ml fluid/day based on ml/kg or 1 ml/kcal (applies only in TF)
________________________________________________________________________________________________
Nutrition Diagnostic Statement :( P related to E as evidenced by S)
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Chronic disease related malnutrition related to HF as evidenced by temporal wasting, weak grip strength, edema,
________________________________________________________________________________________________________
and decreased appetite resulting from cardiac cachexia.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________

Nutrition Intervention/Goals
Goal/s:
_____________________________________________________________________________________________
maintain body weight and reduce edema by 20%
_________________________________________________________________________

Recommendations/Plan:
___Nutrition prescription: _______________________________________________________________
follow DASH diet
___Snacks/supplements___________________________________________________________________
___Provide education_____________________________________________________________________
___Other_______________________________________________________________________________
______________________________________________________________________________________

___Notify ___Physician____Nursing by ___note/ phone/ discuss in person

Monitoring/Evaluation
_____Intake:___________________________________________________________________________
monitor oral intake, to consume 80% of energy requirements
_____Labs/tests_________________________________________________________________________
monitor sodium and fluid intake
_____Wt change_________________________________________________________________________
ensure weight maintenance
_____Other_____________________________________________________________________________
monitor pedal edema

Brandon Harper 09:23

Signature__________________________________Date:______________________Time______________
1/30/2019

Rev 08/2017 labs/FDNT 451

 Gluten
Sources
Free Diet
“The Gluten-Free By: Brandon Harper
Diet.” Beyond Celiac,
www.beyondceliac.org/g
luten-free

https://celiac.org/gluten-free-living/what-is-gluten/sources-of-gluten/
diet/overview/.

What is Celiac Disease?

Celiac Disease
Foundation.
https://celiac.org/about

https://www.beyondceliac.org/gluten-free-diet/overview/
-celiac-disease/what-is-
celiac-disease/.
Accessed February 26,
2019.
Website to Visit:
 Food Recommendations Sample One Day Menu
Gluten Free Alternatives: Breakfast:
1 Cup of Milk
o Amaranth
o Buckwheat Eggs cooked with olive oil
o Brown, White and wild rice Potatoes
o Quinoa
Mixed Berries
What is the gluten o
o
Corn
Cornstarch Snacks:
free diet? o Potatoes
1 small Apple
o Soy Flour
The gluten free diet is designed as o Oats * Peanut Butter
the only treatment for individuals Or
Foods NOT to Eat:
with celiac disease. A person with
this disease can still consume fruits, o Wheat Carrot sticks with Cheese stick
vegetables, meat, poultry, dairy, and o Rye Lunch:
most types of foods, but must avoid o Barley
Quinoa
certain types of grains, flours, and o Brewer’s Yeast
starches. o Triticale Sweet and Sour soy Cubes cooked
with olive oil
Diet Rationale Broccoli
It is very important that anyone who Pear
has Celiac disease does not consume
Dinner:
gluten. Even a small amount of
gluten could cause the person’s body Corn Tortilla
to attack their small intestine and Beans
cause serious damage. These attacks
lead to damage the small fingerlike Cheese
projections that line the small Brown Rice
intestine that absorb nutrients.
Avocado and lettuce
FDNT 452: Medical Nutrition Therapy II Name: Brandon Harper
Lab #6: DM Part A
Please type the lab report and submit via Dropbox in Learning Hub Total Points: _____ / 31
Due: Tuesday, February 26, 2019

Case 18 – Adult type 2 DM: Transition to Insulin

I. Understanding the Diagnosis & Pathophysiology

1. What are the standard diagnostic criteria for T2DM? Which are found in Mitch’s medical
record? (2 pts)
For someone to be diagnosed with Type 2 Diabetes, there are a couple of things that need to be
checked. Fasting blood glucose needs to be above 126 mg/dL, plasma glucose needs to be above 200
mg/dL, 2-hour plasma glucose above 200, or an A1C level greater than 6.5%. After assessing Mitchell
Fagan’s lab values, it was shown that his blood glucose came out at 855 mg/dL the first time and at 475
mg/dL the second time. In addition, the patient’s A1C also came out high at 11.5%. Given these two lab
values, the patient has Type 2 diabetes.
2. Mitch was previously diagnosed with T2DM. He admits that he often does not take his
medications. What types of medications are metformin and glyburide? Describe their
mechanisms (how they work to control blood glucose) as well as their potential side
effects/drug–nutrient interactions. (2 pts)
Metformin is a biguanide which is given to patients with types 2 diabetes because this medication
decreases the amount of glucose produced by the liver while at the same time increasing the amount of
insulin that is absorbed in the muscles. The side effects that come with this medication include nausea,
vomiting, diarrhea, and gas.

Glyburide is a second-generation sulfonylurea which is given in order to stimulate secretion of insulin into
the beta cells. This medication only has one major drawback which is that it can cause hypoglycemia.

3. What other medications does Mitch take? List their mechanisms and potential side
effects/drug–nutrient interactions. (1 pt)
Mitch also takes Dyazide and Lipitor. Dyazide causes the body to produce more urine which in turn helps
reduce sodium levels in the body and get rid of excess liquid in the body such as edema. In doing this,
the medication also helps prevents low potassium levels. While taking this medication some possible side
effects are dizziness, feeling light headed, headaches, or an upset stomach—these side effects can be
made worse if medication is combined with alcohol or marijuana. Lipitor is the medication used in order to
reduce the amount of cholesterol produced by the liver. Because this medication is a statin, it is very
important that it is not combined with grapefruit which can increase the amount of medication in the blood
stream and cause liver damage. Side effects for Lipitor are nausea, constipation, diarrhea, gas,
heartburn, fatigue, headaches and mild muscle soreness.
4. Describe the metabolic events that led to Mitch’s symptoms and subsequent admission to the
ER with the diagnosis of uncontrolled T2DM with HHS. What is HHS? Compare and contrast
HHS with diabetic ketoacidosis. (2 pt)
Mitch has T2DM, this means that he has decreased insulin sensitivity, and therefore has to control his
carbohydrate intake in order to reduce any glucose spikes. However, he has uncontrolled T2DM and he
admits to not taking his diabetic medication regularly. For this reason, his body has not been able to
correctly process and deal with the high amounts of glucose that he was consuming. Therefore, there is
high glucose levels in his blood. This in turn leads to HHS, Hyperglycemic Hyperosmolar Syndrome; this
means that the patient has a very high blood glucose ranging from 400-2,800 mg/dL. These patients are
also dehydrated, they feel confused, can hallucinate or even fall into a coma. The dehydration causes the
concentration of blood glucose to be even higher. All the symptoms were present with Mr. Fagan
including the confusion and dizziness and they were treated by rehydrating and providing insulin.
Diabetic ketoacidosis is a complication or disturbance with carbohydrate, protein and fat metabolism. It is
a result of inadequate insulin and so the body depends on fat for energy and ketones are formed. The
acidosis results from the increased production of acetoacetic acid and 3-beta-hydroxybutyric acid from
fatty acids. As a result, ketones spill into the urine. This complication is also characterized by high blood
glucose levels ranging from 250-600 mg/dL generally and dehydration, but it differs from HHS in its
symptoms. Symptoms are polyuria, polydipsia, hyperventilation, and fruity ketone orders.

5. HHS is often associated with dehydration. After reading Mitch’s chart, list the data that is
consistent with dehydration (biochemical, etc). What factors in Mitch’s history may have
contributed to his dehydration? (2 pts)
Mitchell Fagan showed signs of being dehydrated by displaying poor skin turgor along with cloudy and
amber urine. The cause for this dehydration is due to several different reasons. Recently the patient has
been vomiting for the past 12-24 hours and as only has “sips of water.”

6. Describe the insulin therapy that was started for Mitch. What is Lispro? What is glargine? How
likely is it that Mitch will need to continue insulin therapy? (2 pts)
Currently, Mr. Fagan has been placed on Lispro every 2 hours until his glucose is within normal limits
(150-200 mg/dL). Then at night begin glargine at around 9pm. Lispro is a fast-acting insulin analog. It is
different than human insulin, but it binds to insulin receptors the same way that human insulin does.
Glargine is a long acting insulin which regulates insulin over 24 hours because it is absorbed slowly. It is
uncertain whether the patient will need to continue being on insulin since his lab values are not normal
yet.

II. Understanding the Nutrition Therapy

7. Outline the basic principles for Mitch’s nutrition therapy to assist in control of his DM. (3 pts)
In order to assist Mr. Fagan, there are several steps that need to be taken. First, the patient needs to be
taught about carbohydrates and how they impact him. He should learn what foods are carbs and how
they will impact his blood sugar along with how much insulin he needs for each meal. Second, the patient
will have to start monitoring the amount of carbohydrates that he consumes along with his sodium
restriction. Carbohydrates directly impact his blood glucose and because he has type 2 diabetes this
needs to be monitored. Finally, weight management should be considered. The patient is currently obese
and has a BMI of 31 which is most likely contributing to his insulin resistance. A good approach would be
exercising and slowly losing weight in order to increase the insulin sensitivity in the patient.
III. Nutrition Assessment

8. Assess Mitch’s weight and BMI (use UBW since he was dehydrated) what would be a healthy
weight range for Mitch? (To calculate healthy weight range use a BMI of 25-27) (1 pt)
BMI = 103.6/(1.75)2 = 33.8 Obese
Healthy weight Range: 168-182lbs
IBW: 160lbs
5 feet = 106lbs
9 in: 54lbs
%IBW: 143%
Adjusted Wt: (228-160) x 0.25 + 160 = 177 lbs

9. Identify and discuss any abnormal laboratory values measured upon his admission. How did
they change after hydration and initial treatment of his HHS? (3 pts)
Sodium (136-145 mEq/L): patient had low range coming in at 132 but was increased to 135 after
hydration
BUN (6-20 mg/dL): started out high at 31, but was lowered to 20 after hydration
Creatine (0.9-1.3): started out high at 1.9 but was lowered to 1.3 after hydration
GFR (>60): started out low at 39 but was raised to 62 after hydration
Glucose (70-99 mg/dL): started out extremely high at 855 was lowered after hydration to 475
Phosphate (2.2-4.6 mg/dL): started low at 1.8 and was slightly increased to 2.1 after hydration
Anion Gap (10-20 mmol/L): started low at 6 but was increased into normal range at 11
Osmolality (275-295 mmol/kg/H20): started extremely high at 322.6 but was lowered to 303.5
Cholesterol (<200 mg/dL): started high at 205 and there was no second value
VLDL (7-32 mg/dL): started high at 37 and there was no second test
Triglycerides (40-160): started high at 185 and there was no second test
HbA1C (<5.7%): started high at 11.5% and there was no second test
WBC (3.9-10.7): started out high at 13.5 and there was no second test
Hematocrit (41-51): started out high at 57 and there was no second test
Specific Gravity (1.001-1.035): came out high with 1.045
Protein: came out high at 10
Glucose: came out high at 3
Ketones: came out high at 1
IV. Nutrition Diagnosis
10. Prioritize two nutrition problems and complete the PES statement for each. Only use one on
the ADIME note for evaluation using the NCP Rubric. (1 pt)
Excessive carbohydrate intake related to food and nutrition knowledge deficit concerning appropriate
amount of carbohydrate intake as evidenced by fasting glucose of 855 and 475 mg/dL and A1C of 11.4%.
Elevated A1C related to food and nutrition related knowledge deficit as evidenced by A1C over 6.4%.

V. Nutrition Intervention

11. Determine Mitch’s initial CHO prescription using his diet history and your assessment of his
energy requirements. (Tip: use 50% of total calories from CHO) (1 pt)
How many total grams of CHO? How many grams each meal? How many carbohydrate
servings per meal?
Based on Usual body weight because the patient is currently dehydrated but is being rehydrated. Using
20kcal per kg because he is obese
Energy: 20kcal x 103.6kg = 2,072 kcals
2,072kcals x 0.5 = 1036 kcals
1036kcals/ 4kcals = 259g
259g/15g = 17 exchanges
17exchanges/4meals = about 4 (4.25) exchanges per meal

12. Mitch also has hypertension and high cholesterol levels. Describe how your nutrition
interventions for diabetes can include nutrition therapy for his other conditions. (1 pt)
Because Mr. Fagan will be consuming less carbohydrates and less unhealthy fats, his overall health will
be improved. He already claims to eat low sodium foods and by making his diet overall healthier will
benefit him greatly.
Complete an ADIME note. (10 pts)
Nutrition Assessment
DX PMH___________________________________________________

Sex Age Wt Ht_______ABW IBW______________ % IBW_______

UBW___________%UBW_________% Wt. Δ_____________BMI___________

Labs Glu Bun Cr Na K+ Chol TG Alb_______

Hgb Hct A1c Others(s) ______________________________________________

Pertinent Medications ____________________________________________________________________________

NFPA:
GI: N V D C Dentition Skin Condition Vital Signs T_____BP____

Current Diet Order/regimen Food Intake_________________________

Fat/Muscle Loss _____________________________________________Edema: none +1____+2_____+3_________

Micronutrient Exam: ___________________________________________________________________________

Estimated nutrition Needs:
______________________ kcal/day based on __________________________________________________________
______________________protein/day based on_____________ g/kg)
ml fluid/day based on ml/kg or 1 ml/kcal (applies only in TF)
________________________________________________________________________________________________
Nutrition Diagnostic Statement :( P related to E as evidenced by S)
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________

Nutrition Intervention/Goals
Goal/s:
_____________________________________________________________________________________________
_________________________________________________________________________

Recommendations/Plan:
___Nutrition prescription: _______________________________________________________________
___Snacks/supplements___________________________________________________________________
___Provide education_____________________________________________________________________
___Other_______________________________________________________________________________
______________________________________________________________________________________

___Notify ___Physician____Nursing by ___note/ phone/ discuss in person

Monitoring/Evaluation
_____Intake:___________________________________________________________________________
_____Labs/tests_________________________________________________________________________
_____Wt change_________________________________________________________________________
_____Other_____________________________________________________________________________

Signature__________________________________Date:______________________Time______________

Rev 08/2017 labs/FDNT 451