Download Biochemical Data, Medical Tests and Procedures

NCP Case Study
Case (patient) Information: Name Redacted for Privacy
Step #1: Nutrition Assessment
Nutrition Assessment
Categories
Biochemical Data, Medical
Tests and Procedures
Anthropometric
Measurements
Nutrition-Focused
Physical Findings
Food/Nutrition-Related
History
Client History
Social:
Medical:
Family:
Medications:
Case Example Indicators
Albumin(BD-1.11.1): 3.7g/dL (4.0g/dL or higher),
Hemoglobin(BD-1.10.1): 10.7✓(10-11.5), Calcium(BD1.2.9) 9.0mg/dL✓(8.4-10.2 mg/dL), Phosphorus(BD-1.2.11):
5.7mg/dL  (3.0-5.5mg/dL), PTH Intact(BD-1.5.10):
439pg/dL✓(150-600 pg/mL),Potassium(BD-1.2.11):
4.2mEq/L(3.5-5.5mEq/L), spkt/v Dialysis: 1.38✓(1.2 or
higher). Cholesterol, serum(BD-1.7.1):
128mg/dL(<200mg/dL), HGBA1c(BD-1.5.3): 6.4%(<7%)
Height(AD-1.1.1): 5’0”(152.4cm), Weight(AD-1.1.2):
195#(88.45kg), Frame size(AD-1.1.3): Medium, Weight
Changes(AD-1.1.4): 3-5# fluctuations due to dialysis,
BMI(AD-1.1.5): 38.1(Obesity Class II)
Obese(PD-1.1.1), Cataracts, Blurry vision(PD-1.1.6), Edema
of the legs and fingers(PD-1.1.4), Diarrhea(PD-1.1.5).
Decreased appetite.
1019kcals/day (FH-1.1.1), 380 kcals/carbs.(FH-1.5.3.1), 180
kcals/protein(FH-1.5.2.1), 458kcals/fat(FH-1.5.1.1),Sodium:
1495mg(FH-1.6.2.7), Potassium: 792 mg(FH:1.6.2.5), Fiber
7g(FH-1.5.4.1), Phosphorus(FH(1.6.2.6): 717mg/day,
Fluid~500mL(FH-1.2.1.1), Calcium(FH-1.6.2.1) 411mg,
Added sugars(FH-1.5.3.2) 12g. Cholesterol 532mg
Pt. is 70 years old (CH-1.1.1), female (CH-1.1.2), Caucasian
(CH-1.1.3), Grandmother and caretaker of two children, ages
5&11(CH-1.1.7)(CH-3.1.2) and has limited mobility(Uses
cane)(CH-1.1.10) Pt was diagnosed with Type 2 Diabetes at
age35 (CH-2.1.4), pt has Diabetes Retinopathy,
Nephropathy(CH-2.1.3), and Neuropathy(CH-2.1.11). Pt has
non-functioning kidneys (15% usable)(CH-2.1.3). Pt has
been diagnosed with IBS (CH-2.1.4).Pt is on hemodialysis
3x/week(CH-2.2.1) in a care center. Pt sometimes
experiences edema (CH-2.1.8). Pt spends most of her time at
home, lacks social interaction, and no longer can enjoy the
activity of reading with the onset of retinopathy.
Pt has a family history of genetic related cancers including
rectal and Breast cancer on her Mother’s Side. Father passed
away from aneurisms; Heart disease runs on her father’s
side.
Medications: Insulin: Relion N and R; 20/10, 20/10 by
injection, Bystolic (once a day), Mitrin(When needed), Baby
Aspirin: 81mg/1x/day, Renavite: 1xday/1 pill, Bumex(2 pills
2x a day)
Comparative Standard
Estimated Calorie Needs: 1470kcals/day(Mifflin-St.
Jeor)(CS-1.1.1), Protein:106g/day(1.2g/kg)(CS-2.2.1),
Carbohydrates: 165g-238g/day(AMDR Method)(CS2.3.1),
Fat: 74-129g(AMDR Method)(CS-2.1.1), Estimated fluid
needs: ~1000mL/day(CS-3.1.1), Estimated Potassium needs:
</=2000 mg/day(CS-4.2.5), Sodium needs:
<1500mg/day(4.2.7), Phosphorus needs: </=
1000mg/day(CS4.2.6)
IBW: 100#(Hamwi Method) (CS-5.1.1), Recommended BMI
18.5-24.9, Calcium: 1200mg/day(AMDR Method)(CS4.2.1), Estimated Fiber Needs: 20-25g/day(CS-2.4.1)
Step #2: Nutrition Diagnosis
1. Excessive fat intake (NI-5.7.2) as related to undesirable food choices(NB-1.7), selfmonitoring deficit(NB-1.6), limited adherence to nutrition-related recommendations (NB1.6) as evidenced by 45% of kcals from fat, UBW: 195#, Class II Obesity, intake is lacking
in vitamins, diarrhea.
2. Limited adherence to nutrition-related recommendations (NB-1.6) as related to
undesirable food choices (NB-1.7) as evidenced by 45% of kcals/fat, diarrhea, Class II
Obesity, Symptoms of uncontrolled Diabetes type II, and not ready for diet/lifestyle change.
Nutrition Prescription: (nutrient needs + recommended diet/regimen)
Estimated Calorie Needs: 1200 kcals/day, 400 kcals/day from Protein, 500 kcals/day
from carbohydrates, 300 kcals/day from fat. <5% of calories from saturated fat, 2g
Potassium, 1 g Phosphorus, 1.5 g Sodium, ~1000 mL/day of fluid, 15-20 g/day of fiber,
1.2 g/day of Calcium,
Step 3# Intervention
1. Nutrition Education or nutrition relationship to health/disease(E-1.2) to help patient
understand the importance of her diet to her disease
a. Goals: Pt will be able to understand the importance of her diet to her disease.
2. Nutrition counseling (Trans theoretical model (C-1.4) using rewards (C-2.10) and
motivational interviewing (C-2.1) to inspire patient to get to the contemplation stage.
a. Pt will move from the pre-contemplation stage to the contemplation stage.
3. RD will refer patient to senior community program in South Plainfield (RC-1.6) to get
social interact.
a. Pt will attend senior community program for social interaction 1-2 times a week.
4. Nutrition counseling using goal setting to have patient maintain proper diet described in
nutrition prescription.
a. Pt. will be able to follow diet 3x a week.
5. Nutrition education about high fiber low phosphorus/potassium foods.
a. Pt will be able to identify 5 high fiber low phosphorus/potassium foods/
6. Nutrition education about the effects of high-fat foods in diabetes and IBS.
a. Pt will be able to identify 3 high fat foods in her diet
b. Pt will be able understand the effects of high-fat foods in diabetes and IBS.
7. Nutrition counseling using self-monitoring.
a. Pt will record diet using a voice recorder application on her phone 2x a week.
8. Referral to Physical therapist for physical activity.
a. Pt will attend physical therapy 1x week for physical activity.
Step #4: Nutrition Monitoring & Evaluation
How you will monitor success of intervention(s) and evaluate progress toward goal(s)
When/time frame you plan to reassess: 2 weeks________________
1. Indicator: Education about Disease as related to diet
a. Criteria: Pt will take a small basic quiz about her diet as related to her disease.
2. 2. Indicator: Stages of Change
a. Criteria: Pt will move from pre-contemplation to contemplation stage.
3. Indicator: Attendance at Senior Community Center
Criteria Pt will attend Senior Community Center in Plainfield 1-2x a week.
4. Indicator Education: High Fiber/low phosphorus/potassium foods.
Criteria Pt will be able to identify 5 foods out of 10 that are listed by the RD.
5. Indicator: Education: High Fat foods
Criteria: Pt will be able to identify 3 high fat foods.
6. Indicator: Education: Effects of high fat foods in diabetes and IBS
Criteria: Pt will answer true and false questions about fat in the diet for diabetics
and those with IBS.
7. Indicator: Self-Monitoring
Criteria: Pt will record diet 2x a week using voice recorder.
9. Indicator: Appointment with PT
a. Criteria: Pt will attend an appointment with a physical therapist.
If a reassessment addresses goal progress: