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Kelsey Fenton NTR 401 Assignment # 3 12/9/11 Outline of counseling session In the initial visit, I spoke with Shelby about her lifestyle choices, such as physical activity level, smoking, eating habits and alcohol consumption. Additionally I questioned her about any food preferences and food aversions. She contested to the fact that she avoids most fried foods as they upset her stomach, and she experiences severe abdominal cramps when she consumes starchy foods. Shelby also dislikes vegetables and rarely eats them. Shelby prefers to eat fruits and they are healthy and she likes many of them. She also enjoys fish and admits that this is usually her main source of protein. She frequently eats out, about 3-4 times a week, and generally eats twice a day, and usually does not eat breakfast. She doesn’t cook much as she usually eats alone, and doesn’t like to cook for herself. She’s willing to learn more about cooking, and is interested in finding some fast, healthy recipes for delicious food she can prepare at home. Shelby rarely drinks alcohol, as this will often upset her stomach. She does not smoke cigarettes, and exercises 3-4 times a week for 1 hour, most of which is cardio. She is a full time student and works 25 hours a week at a convenience store. She does not receive financial support from her family, and is living on a tight budget. She does not partake in any extracurricular activities, and enjoys spending free time with friends. Shelby Lubbers 21 years old, female Height: 5’ 5 Weight: 105 lbs BMI: 18.5 Food Synopsis Below is a list of foods suggested for Shelby based off her preferences and aversions. It’s important that Shelby read the ingredients of anything that is pre-packaged or frozen, as these items can sometimes contain gluten. Fruits and Vegetables Try eating 5-9 servings of these a day. They are gluten free. Frozen fruits and vegetable sold without added ingredients are also gluten free. Try eating broccoli (steamed) with cheese sauce for dipping. Spinach salad is another great way to get your greens, throw in your favorite fruits, toppings, cheeses, croutons, and dressings to spice it up a little. Green beans are very nutritional, and contain carbohydrates, which serve as energy. Try sautéing them in some butter with a little garlic for flavoring. Cereal Look for gluten free cereals, these can be found in your local co-op or health food stores. Gluten Free Oats are also another alternative Pasta Avoid Couscous as this contains wheat. Most rice is gluten free, but be careful with the seasoning agents as many of these could have traces of gluten. Look for gluten free pasta, and read the ingredients of sauces, some of which may contain gluten. Dairy Butter, cottage cheese and sour creams don’t contain gluten. Some milk is made with malt should be avoided. Ordinary Milk is fine. Be cautious of blue cheese and other aged cheeses. Meat/Poultry/Fish Try and purchase these items fresh that are free of seasonings, and are left plain. Read the ingredients on frozen varieties, as sometimes traces of gluten can be included. Eggs are high in protein and gluten free, try eating these for breakfast, with some type of fruit. Be cautious of processed, luncheon meats, as some of these have gluten ingredients Salmon, tuna, cod, and halibut are all delicious cuts of fish, and all free of gluten. Try baking these and seasoning them with little pepper, lemon, or garlic for taste Frozen Foods Ice cream is usually okay; just beware of cookie chunks, gram crackers, and starches that may be added in the mix. Most fruit bars and popsicles are okay, just be sure to check the ingredients for gluten traces. Many frozen dinners with sauces have gluten ingredients, avoid these Beverages Coffees, tea, sodas, and milk, are all gluten free Avoid beer and liquor as they contain gluten. There are gluten free beers, which are available at your local co-op. Rice liquor, and wine may be good alternatives for ordinary liquor. Brochures for celiac disease (web generated) these links have good information available in brochures for patients with celiac disease. Http://www.purdue.edu/hhs/hk/documents/honors499/Spring%202008/Celiac_ Disease2.pdf http://www.celiaccentral.org/SiteData/docs/NFCA%20WOMEN/019c0a188ed589 2f/NFCA%20WOMENS%20HEALTH.pdf Http://www.celiaccentral.org/education/Women-s-Health/ClinicianResources/440/ NCP Assessment: Signs and Symptoms- Bloating, Abdominal cramping, diarrhea, gas, and constipation High level of celiac antibodies present in the blood. Diagnosis PES statement Inadequate carbohydrate intake related to impaired glucose tolerance and energy malabsorption as evidenced by weight loss, abdominal pain, bloating, delayed gastric emptying and high levels of anti-endomysium and anti-tissue transglutaminase. Intervention Avoid foods containing barley, Bulgar, Durum, Farina, Graham flour, Rye, Semolina, Spelt, Triticale, and Wheat. To increase carbohydrate intake, encourage foods that are a good source of carbohydrates and gluten free, such as vegetables, wild rice, and gluten free pasta, which she could pair with her favorite protein, fish. Provide information and resources about healthy recipes that are gluten free and time efficient. Encourage her to eat a well balanced breakfast, a meal rich in carbohydrates and protein, like eggs with a slice of gluten free toast and a glass of orange juice. Provide resources and education on label reading Stress the importance of reviewing the ingredients on labels of foods and supplements to avoid sources of gluten, which may be present in some of these. Education on food cross contamination Inform Shelby about the cautions of eating out, explaining cross contamination, and how she needs to make sure she is eating food that is prepared gluten free. Monitoring and Evaluation Antibody levels Gluten free dietary pattern Potential exposure to cross contamination Review the changes in client status (gastrointestinal, immune, neurological and physiological status) as well as her social status (social and medical support, stress level) Monitor symptoms such as bloating, gas constipation and diarrhea, bacterial overgrowth 24 hr recall Breakfast Apple slices 1 cup Oatmeal, instant, 1 cup Fat free milk, 1 cup Lunch Wild and brown rice, 1 cup Chicken baked (3 oz) Dinner Salmon, baked (3 oz) seasoned with lemon juice and garlic salt Mashed potatoes (1 cup) Margarine (1 tbsp) Ice cream (1 medium scoop) Total Estimated Calorie Intake: 1300 kcal Recommended Calorie intake: 1800 kcal *Gathered from mypyramid.gov NCP Assessment Weight loss of 6 lbs. higher levels of celiac antibodies present in the blood. Patient looks weak and frail, complains of increased abdominal pain, gas and constipation. She declares she is unable to eat the suggested foods, and is experiencing severe lethargy Diagnosis Inadequate nutrient intake related to food aversions and nutrition/food knowledge deficit as evidenced by continued weight loss, and a BMI of 17.6, indicating malnourishment Intervention Recommend taking a daily multivitamin, as she is deficient in essential nutrients, vitamins, and minerals based off of caloric intake. Stress the importance of staying away from foods that contain gluten, such as oatmeal. Suggest she switch to gluten free oatmeal, which provides much of the same vitamins and minerals in ordinary oatmeal. Examine what foods she would be open to trying, give her a list of vegetables that she may not be familiar with and encourage her to try them. Explain 1 serving of most vegetables is equal to 15 grams of Carbohydrates. Recommend liquid protein and carbohydrate rich beverages, which will supply her with calories she needs to meet her 1800 kcal needs. Reduce exercise to light/moderate physical activity twice a week until patient has reached a healthy weight. Consult with physician about prescribing medications that control intestinal inflammation, such as steroids. Monitoring and Evaluation Monitor weight loss, symptoms such as gas, constipation, and abdominal cramping. Monitor compliance with gluten-free diet, review any changes in medical status (gastrointestinal, immune, neurological, and psychological) Additionally, follow up on patient’s intake of steroids; collect information about any changes in medical status What I learned… As the RD in this experiment, I feel I provided a lot of choices and good information about gluten free dieting. I also explained the importance of complying with a gluten free diet as this will help eliminate some of the gastrointestinal discomfort she frequently experiences while eating certain foods. I also felt like I carried out the Nutrition Care Process very well, and developed realistic goals, which I felt the patient was capable of obtaining. I developed good rapport between the patient, and me and listened to her desires, as well as her concerns. I tried to implement changes within her diet based upon preferences she listed. I also tried to encourage that she experiment with new foods to eliminate some of the food aversions she has towards vegetables. I feel that listened well, and conveyed respect throughout our initial visit I expressed empathy for her discomforts with gluten intolerances, and developed strategies and suggested foods that would be good alternatives. I made an accurate diagnosis based off the signs/symptoms and data I collected in the initial visit, and developed good intervention strategies, which I believed, would resolve the problem. Though my client still struggles with consuming enough calories to satisfy her energy needs, she is in the action phase of implementing some of the changes and strategies we’ve developed and discussed. I believe she is ready, willing and capable to do this, she just needs to explore her choices more, and find foods, which she can tolerate and serve as alternative sources of energy. In summary, I found this experience to be very realistic and exciting. It allowed me to practice and apply many of the skills I’ve acquired throughout my educational career. It gave me a sense of accomplishment and reward that I’ve been yearning for. As the client, I was a tough case to resolve because of a debilitating illness that drastically affected my appetite, resulting in a reduced food intake. I couldn’t partake in the recommended diet because I couldn’t eat. I’m sure had I been healthy and with an appetite, the dash diet would have worked well. I know this diet is designed for people who struggle with hypertension, though I’m not one of these people, I believe it’s important to moderate and limit salt intake as it can only benefit your health. While I did not partake as the client in this experiment, I can appreciate the fact that this diet would be ideal for many individuals living in this country today. I also acknowledge the resources and information given by the RD who displays competent knowledge about this subject matter. In summary, I feel that this diet change is a great experience, and can give us insight about what situations we may come across in our professional careers as Registered Dietitians. Works Cited Evidenced Based Nutrition Practice Guideline on Celiac Disease. 23rd June 2009. American Dietetics Association. http://www.adaevidencelibrary.com/topic.cfm?cat=3677 Gluten Intolerance. 2010. Giforkids. http://www.giforkids.com/?a=utrition&celiac%20Disease%20Gluten%20Intoleran ce