Nutrition First Office Call

Pt Initials: KA

Appointment length: 60 min

ASSESSMENT
Client History
Reason for visit: Referral for management of overweight and HTN
Personal hx: 42 yo married F, reports no tobacco use
Medical hx: Knee PCL ligament tear from skiing accident, healed well
Family Med hx: Both parents are overweight with high blood pressure, controlled by
medications
Social hx: Nurse at Seattle Childrens Hospital, busy and stressful work environment, recently
promoted to managerial position and is seated for most of the day, works 55-60 hours/wk,
financially stable,
Food and Nutrition-Related History
Food and Beverage Intake and/or Nutrition Intake Analysis Results: Diet consists of three
meals and two snacks per day. Reliance on convenience foods and her husbands cooking.
Consumes about 2185 kcal/d (123% of estimated needs). Consumes 49% of AMDR fat
recommendation. By kcal, largest meal is lunch. Socially drinks with family 2-3 drinks per month.
Consumes 58% of DASH standard for potassium. Consumes 74% of RDA recommended amount
for Magnesium. Consumes 109% of the DASH recommended amount for sodium. Consumes
408% of DASH recommended amount for cholesterol. Consumes 267% of DASH recommended
amount for saturated fat. Reports low intake of fruits, vegetables, and whole grains. Doesnt
consume any added sugars in her diet.
Food and Nutrition History: Prior to Feburary 2013, pt ate a mostly plant-based diet, rich in
whole grains, fruits and vegetables. In the last two years, pt. gained a significant amount of
weight, after starting a sedentary job and reliance on spouses cooking. Recently started eating
mainly what her husband cooks a meat and potato diet
Knowledge/Beliefs/Attitudes/Behaviors: . Eats out once per week at sit-down restaurant with
husband. Pt states that she doesnt want to seem picky or ungrateful to husbands cooking, and
always eats what husband cooks (mainly meat and potatoes). Pt meal times are rushed. Pt states
that she has picked up bad habits from husband. Pt expresses interest in starting the DASH diet,
but is having problems implementing it. Pt. wants to stay away from medication and would
rather control her high blood pressure with DASH diet.
Food Access and Preparation: Pt has good access to food and relies on convenience foods
and her husbands cooking for preparation.
Food allergies/Intolerances: None reported
Physical Activity: Briskly walks 5-6 days per week for 30-45 minutes, in woods near her house
Medications and Dietary Supplements: currently taking progesterone oral contraceptive pills
Anthropometric Measurements
Height (in/cm): 64 in/162.2 cm
Weight (lb/kg): 176 lb/79.8 kg
BMI: 30.3 (obese)
Weight hx: Pt has gained 22 pounds within the last 3 years, and was weight stable
prior to that
Other measurements: N/A
Ideal/reference weight: 120 lbs
Usual weight: 154lb/70 kg
% Wt change: 14%
Desired weight: N/A

%ideal/reference weight: 146%

%usual weight: 114%
Weight change classification: N/A

Biochemical Data, Medical Tests and Procedures

Pertinent labs/tests/procedures: cholesterol of 210 mg/dL, low HDL of 45 mg/dL Glucose 88

mg/dL(WNL), Triglycerides 130mg/dL (WNL), LDL 101 mg/dL (WNL)
Nutrition Focused Physical Exam Findings
GI Function: Not assessed
Sleep hx: Pt reports sleeping 7-8 hrs/night
Energy: pt rates her energy levels as moderate to high, pt appears well rested, with adequate
energy
Stress: Pt rates her stress level at moderate to high
Blood pressure: 137/88, prehypertensive
Overall clinical observation: Pt appears interested in adopting the new DASH diet, wellrested, good energy, and not stressed.

DIAGNOSIS
Problem: Overweight/Obesity (Class 1 NC-3.3.3)
Etiology: high-energy intake and sedentary lifestyle
Signs and Symptoms: BMI 30.3 (obese)
Problem: Undesirable Food Choices (NB-1.7)
Etiology: not containing the skills necessary for implementing the DASH diet
Signs and Symptoms: consumed 13% of DASH recommendation for fruits and 63% of DASH
recommendation for vegetables

INTERVENTION
Nutrition Prescription
REE/ Kcals: 1441 kcal (Mifflin x 1.2 1.3) = 1729- 1873kcal/day -250 for weight loss =
1479- 1623 kcal/day
Protein (g/kg): 0.8-1.0 g/kg w/ BW adjustment of 60.5 kg =48.4- 60.5g/kg
Fluids (ml/kg): 35 mL/kg w/ BW adjustment of 60.5 kg =2118ml/kg
Other: follow DASH recommendation of 1600 kcal diet.
Intervention 1: Food and/or Nutrient Delivery - Decreased Energy Diet (ND-1.2.2.2)
Explained that pts current calories exceed desired calories. Gave pt a choice in either creating a
calorie deficit through an increase in physical activity, or calorie reduction. Pt agreed to
implement a 1600 Kcal DASH diet. Pt agreed to a calorie reduction by incorporating 3 oz or less
of lean meat for lunch for 5 out of the next 7 days. Provided pt with a meat portion size handout.
Provided pt with a food log and asked pt to record the lean meat options and amounts for 5 out
of the next 7 days.
Intervention 2: Nutrition Counseling- Problem Solving (C-2.4)
Problem solved various ways to implement a 1600 kcal DASH diet. Brainstormed which meals in
pts current diet to make DASH compliant for this week. Pt decided to start by switching her
afternoon snack to a DASH compliant snack. Provided pt with a handout of different DASH snack
options, and discussed the handout together. Pt decided to implement the DASH compliant snack
of one piece of fruit and one serving of whole grains for 5 out of the next 7 days. Provided pt with
a food log to record specific snack choices for 5 out of the next 7 days.

MONITORING /EVALUATION
Professional goal#1: To address obesity, at one-week follow-up, pt will present a food log of 3
oz of lean meat for lunches, 5 out of the next 7 days.

Professional goal#2: To address hypertension, at one week follow up, pt will present a log that
reflects consumption of 1 serving of fruit and 1 serving of whole grains for the afternoon snack
for 5 out of the next 7 days.
Follow up: fat intake, fiber intake
Handouts provided: food log, DASH snack handout, portion size handout
Clinician signature: Kelly Galloway