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Sage Dietetic Internship Inpatient NCP Form

Patient Name: E.R.


Admit Date: 12/4/15

Current Date:
12/10/15

Reason for Nutrition Consult: Initial Nutrition Assessment


Admit Medical Diagnosis: Vertebral fracture

NUTRITION ASSESSMENT
Food and Nutrition Related History:
Resident reports eating healthy and cooking meals at home. Daily selective menus reviewed; she self-selects menu.
Current issues with decreased appetite due to constipation.
Current Inpatient Diet
Order:
Regular; thin liquids

Feeding Ability
Independent
Limited Assistance
Extensive/Total Assistance

N/A

Explain:
Resident is able to feed herself
independently without set up
help.

Oral Problems
Chewing Problem
Swallowing Problem
Mouth Pain
None of the Above
Explain:
Resident has no difficulty
chewing/swallowing or mouth pain at this
time. None observed during meal rounds.

Physical Assessment:
Resident is alert and oriented x3, and is able to make needs known. She is ambulatory and needs assistance getting
up, walking, toileting, etc. due to recent fracture. Skin is intact.
Anthropometric Measurements
Age:
Gender
Ht:
Current Wt: 151# (12/7/15)
BMI:
Admit Wt: N/A
80
Female
63
IBW: 121-147#
26.7
Wt Hx (specify time frame):
resident reports UBW 150#; BMI Classification:
unknown time frame
% Wt change: No significant
Overweight
change
Biomedical Data (list only pertinent nutrition-related labs)
Labs
BUN

Date
23
12/7/1
5
Inpatient Medical Course Relevant to Nutrition (i.e. surgeries, procedures, tests, I/O, etc.):
HX of GERD, anxiety, hypothyroidism, HTN, breast cancer.
PMH:
HX of breast cancer, GERD, anxiety, hypothyroidism, HTN. Resident admitted with vertebral fracture due to recent fall.
Pertinent Medications & Dosage
Senna, Ducosate Sodium, Amlodipine, Losartan, Levothyroxine
Skin status:
Intact Pressure Ulcer/Non-healing wound; Braden Score (only when skin is intact): _______________
Comments:

Skin assessment on 12/7/15.


Estimated Nutritional Needs based on 69 kg
Calories (kcal/kg & total kcal/day)
Protein (g/kg & total g/day)
1,716-2,059 kcal (25-30 kcal/kg)
55-69g (0.8-1.0 g/kg)

Fluid (ml/kg & total ml/day)


1,716-2,059 mL (25-30 mL/kg)

NUTRITION DIAGNOSIS (include IDNT codes)


No new nutrition DX/PES at this time, plan is for maintenance. Resident maintains reported UBW without
significant change. Food and fluid intakes appear adequate to meet nutrient needs (51-75% average).
Regular diet order with thin liquids is appropriate to provide least restriction and promote intake.
Reviewed food preferences and encourage fluid intake to treat constipation. Resident has resolving
complaints of constipation due to pain medication, with Senna and Ducosate Sodium. Hospital labs show
slightly elevated BUN (23 mg/dL) most likely due to recent medical issues. Review labs as available for
improvement. Follow up bi-monthly to check stability. Plan of care is for adequate oral intake and stable
weight.

2014

SGS DI

INTERVENTION
Plan of care is for adequate oral intake and stable weight:
Adequate oral intakes by next review (12/24/15)
Weight will remain +/- 4# of 151# by next review (12/24/15)
Assist with oral intake as needed: set up help
Meet food preferences as able and offer available alternates if resident is not satisfied with meal;
offer snacks between meals if needed
Monitor and encourage intake of food, fluids and snacks during meal rounds and with follow-up;
offer fluids between meals and with medication pass
Monitor for complaints of constipation with meal rounds and follow-up
Monitor nutrition-related lab work as available with follow-up for improvement: BUN
Monitor weight as required for significant change and to meet established goal
Offer resident appropriate bedtime snack daily
Provide medically appropriate diet per MD order: regular diet with thin liquids
Provide nutrition education as needed with meal rounds and follow-up: adequate fluid intakes and
increased fiber to promote bowel regulation
Follow bi-monthly

MONITORING & EVALUATION


Indicators (marker):
Intakes
Weight
Bowel movements
- BUN level

Criteria (SMART Goal specific to marker):


51-75% average
+/- 4# of 151#
At least 1x every 2 days
<23 (or within normal range)

_______________________________________________________________________________________________
Interns Signature
Date

Date

Preceptors Signature

RATIONALE (required section):


1. Discuss reasons for including each abnormal lab:
-

Elevated BUN: indicates hydration status/medical issues

2. Discuss justification for choosing method of calculating needs (specify


equations & references used):
-

2014

25-30 kcal/kg energy: resident is overweight (BMI=26.7)


0.8-1.0 g/kg PRO: resident is overweight
25-30 mL/kg fluids: resident has no HX of CHF, CKD, and is overweight

SGS DI

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