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Sage Dietetic Internship – Inpatient NCP Form
Patient Name: AG
Reason for Nutrition Consult: Nutrition Assessment/Diet Education
Admit Date: 10/12/15
Current Date: 10/13/15
Admit Medical Diagnosis: acute exacerbation of COPD 2/2 community acquired
pneumonia
NUTRITION ASSESSMENT
Food and Nutrition Related History:
24-hour Diet Recall: pt indicated she tends to eat breakfast mid-morning, skips lunch, eats dinner around 4, and snacks at night. Pt said she usually
has toast or cereal for breakfast and eats dinner around 4. Uses Meals on Wheels. Pt stated she is a “grazer” and likes to snack; said she watches her
Na intake, although pt mentioned she loves cheetos and pretzels. Pt diet seems to be high in simple CHO and lacks fiber.
Pt uses a glucometer at home and checks blood sugars 4x/day; stated her blood sugars tend to run in the 100s in the morning and 200 range in the
afternoon, but this varies; pt was not entirely clear on regular blood sugar range.
Pt has history of uncontrolled IDDM
Chronic steroid use do to COPD, resulting in elevated blood sugars
Current Inpatient Diet Order:
Feeding Ability
X Independent
Consistent Carb, 2gNa, 2-3gK, with □ Limited Assistance
2,000ml/24hr fluid restriction
□ Extensive/Total Assistance
□
Oral Problems
□ Chewing Problem
□ Swallowing Problem
□ Mouth Pain
X None of the Above
N/A
Explain:
Explain:
Physical Assessment: well-nourished, awake and alert x3.
Anthropometric Measurements
Age:
67
Ht: 62’
Gender:
F
Current Wt:198lb
Admit Wt: 198lb
IBW: 110lb
Wt Hx (specify time frame):
% Wt change:
BMI: 36.3
BMI Classification: Obese
Biomedical Data (list only pertinent nutrition-related labs)
Date ↓
Labs →
Alb
Cr
BUN
K+
Glucose
Na
Cl
Ca
Mg
10/12
3.4
1.3
41
4.3
161-166
138
100
9.4
1.7
Inpatient Medical Course Relevant to Nutrition (i.e. surgeries, procedures, tests, I/O, etc.): Prednisone taper, with insulin decrease with each
taper. Daily wt monitoring and I/Os
PMH: COPD with chronic steroid use, dCHF, HTN, uncontrolled IDDM, and CKD stage 3 to 4
Pertinent Medications & Dosage: Insulin human nph (10 units daily), insulin Lispro (14 units BID), calcium carbonate/Vit. D (500mg/day),
Lisinopril (10mg/day), Prednisone (30mg/day), torsemide (20mg/day)
Skin status:
X Intact □ Pressure Ulcer/Non-healing wound;
Braden Score (only when skin is intact): _______________
Comments:
Estimated Nutritional Needs based on ____60___________ kg (based on adjusted BW)
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Calories (kcal/kg & total kcal/day)
25-26kcal/kg=1500-1560kcal/day
Protein (g/kg & total g/day):
.8-1.0=48-60g/day
Fluid (ml/kg & total ml/day):
2000ml/24hr fluid restriction
NUTRITION DIAGNOSIS (include IDNT codes)
P (problem)___Undesirable food choices (NB1.7)_____________________
____________________________related to:
E (Etiology) related to 24-hour diet recall and
history of uncontrolled diabetes
____________________________
________________________as evidenced by:
S (Signs & Symptoms):
Diet history indicating excessive simple CHO
and lacking fiber
P (problem)___________________________
____________________________related to:
E (Etiology)____________________________ S (Signs & Symptoms)
________________________as evidenced by:
INTERVENTION
Nutrition Prescription: The pt is currently on a consistent carbohydrate 2gNa, 2-3gK, 2000ml fluid restricted diet. This diet is appropriate for the
patient given CHF, CKD, and DM. The patients estimated energy needs are 1500-1560kcal/day and 48-60g protein/day; this is based on the pts
adjusted body wt of 60kg and it will provide 25-26kcal/kg and .8-1.0g/kg. As noted above, pt lytes are within range and albumin is normal. Pts
glucose levels are within range at 161-166. Pt has a history of uncontrolled diabetes, and given chronic prednisone use, blood glucose levels need to
be closely monitored. I/Os and and weight should be monitored daily to monitor fluid accumulation.
Nutrition Education: As per 24-hour diet recall, pt is consuming a diet high in simple carbohydrates and low in fiber; her eating habits/meal times are
also inconsistent from day to day. Pt tends to eat breakfast mid-morning, skip lunch, eats dinner around 4pm, and snacks at night, but this varies. Pt
indicated that her blood sugars tend to run higher in the afternoon (200s). Pt would benefit from diet education on how to make better food choices
like adding more complex CHO, fruits, and vegetables, and develop more consistent meal habits to better control blood sugars. Pt would also benefit
from education on high sodium foods, as pt is on a Na restricted diet and tends to choose high sodium foods.
MONITORING & EVALUATION
Indicators (marker):
Blood Glucose
Weight
Renal Labs
Criteria (SMART Goal specific to marker):
Blood Glucose: between 100-180mg/dL
Weight: </=198lb
Renal Labs: Na 135-145mEq/L; K+ 3.5-5.5mEq/L; Phos 3.5-5.5mg/dL
_______________________________________________________________________________________________
Intern’s Signature
Date
Preceptor’s Signature
Date
RATIONALE (required section):
1. Discuss reasons for including each abnormal lab: I chose to include electrolytes because the
patient had CKD stage 3 to 4, so although not abnormal at this time, these labs are important to
monitor. Glucose is important to include because the patient is a diabetic and glucose values need
to be monitored frequently to ensure they stay between ~100-180, because both hypo- and
hyperglycemia can be dangerous.
2. Discuss justification for choosing method of calculating needs (specify equations & references used):
To calculate energy needs, I chose to use the patients adjusted bodyweight, since the patient is
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overweight and has a BMI of 36.3. The patients adjusted bodyweight was 60kg, and I chose to
provide 25-26kcal/kg, since the patient is not currently in a hyper-metabolic state. This will allow
for weight maintenance, or even weight loss, which would be beneficial for the patient. I chose to
use .8-1.0g of protein/kg because she has CKD stages 3 to 4 and she is not on dialysis, so protein
intake needs to be monitored.
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