Melanie Daniel

COLLEGE OF SAINT ELIZABETH Dietetic Internship Program 2018-2020

Indepth Nutritional Assessment Worksheet - Med-Surg and Extended Care

Data Gathering Section

1. Patient Information:
Client Initials _CM_ Room Number Admit Date 4/14/19 Age __48____ Gender ___F____

* Speech or Language Barrier _____N/A____

2. Admitting Data (Source: Nursing Admission Form, Physician’s Hx and Physical, etc.)

Admitting Diagnosis or reason for outpatient visit- L empyema s/p L VATS decortication

Reported Symptoms (Sx) – chest pain

Past Medical History (PMH) –HTN

Significant Family Hx –
 Mother- Alzheimer’s, DM, HTN, DVT, liver disease, autoimmune disease
 Father- DM, heart disease

Current Diet Order: Regular

Nutritional History Section(please explain all yes answers)-

1. General Habits:
Previously on a modified diet prescribed by physician? Yes No
If yes, what kind? How long?
Pt was put on a cardiac diet by MD at OMC, however pt put on Regular diet at MMC. Pt also reports following a regular
diet at home.

Do you still follow this diet? Yes No

Barriers and/or problems adhering to modified diet?

Pt states will use Mrs. Dash and reduce salt intake when discharged.

Are there any foods you do not tolerate? Yes No

Nausea and Vomiting? Yes No

Constipation/Diarrhea? Yes No
Swallowing/chewing problems? Yes No

Comments:
Pt reported nausea 2/2 pain meds per pt, but no vomiting- on Reglan/Zofran. Pt reported constipation- pt on Colace/MOM-
encouraged to increase fiber/fluid intake. No swallowing/chewing difficulty, however pt prefers soft texture foods 2/2
recent procedure.

Do you take any vitamin/mineral supplements? Yes No

If yes, please identify kinds and frequency:
 MVI

Were these vitamin/mineral supplements prescribed by your physician? Yes No

If yes, explain:
 MVI (1x day)- to promote overall health

If no, who recommended:

Do you take any other type of nutritional or herbal supplement? Yes No

If yes, explain:
Melanie Daniel

Any changes in appetite or eating habits over the past year? Yes No
If yes, explain:

Do you have any food allergies? Yes No

If yes, explain:

2. Weight and Height Hx obtained from Patient You should also consider weighing patient if ambulatory:
Usual Weight: _198# Current Weight: _185#_(83.9kg)_ (Date taken _4/14/19_)

Any changes in weight over the past: No Yes: 3 mos. ___; 6 mos. _ X__; or > 1 year ________
(If patient cannot remember, ask if they noticed a change in how clothing fits and when.)

 Pt had a 6% weight loss in 6 months per pt, which is not significant. Per EHR, 5# weight loss x 1 month
documented.

Was this weight loss/gain intentional? No Yes

If yes, Highest weight ________ Lowest weight _________

Usual (adult) Height: _5’1”_ Current Height __5’1”___ (Date taken 4/14/19 )
Have you noticed a change in your height recently? Yes No

Calculations:

IBW: 48kg (Upper IBW: 52.5kg) %IBW: 176% Adjusted Body Weight: BMI: 35 % wt change: 6% time frame of
change: 6 months

Estimated Kcal needs: Please indicate formula used Other:

 Weight: 52.5kg (Upper IBW)
 28-30kcal/kg
 1,470-1,575kcal

Estimated Protein needs: Please indicate standard used

 Weight: 52.5kg (Upper IBW)
 1.2-1.3g/kg
 63-68g

Estimated Fluid needs: Please indicate standard used

 Less than or equal to 1,500mL

3. Social Hx:
Do you smoke? Yes No If yes, explain
Do you have a (past) history of smoking? Yes No If yes, explain:

How frequently do you drink alcohol? Never Occasionally Daily

If consumed, what kind and how much?
Socially. Pt reports intake varies, however she will most likely drink 2-3 glasses of wine on the weekend.

Briefly describe your exercise habits or physical activity level.

Pt reports walking occasionally and has access to free treadmills at work, which she uses on occasion.

Any disabilities that limit activities of daily living (ADL)? Yes No

If yes, explain: H/o edema, dementia, SOB.

Does patient require use of aids and/or prosthetics (circle items): N/A
Eye glasses Hearing aid Dentures Walking support
Melanie Daniel

Eating Utensils Other: _________

Other: Is patient able to read and write? Yes No Is patient educable? Yes No

4. Current Medications – Indicate potential diet/drug interaction(s) for each and describe action of medication. Also, give
dose and/or time for key meds such as insulin and dose for any therapeutic vitamin or mineral, etc. Include SMBG if
appropriate.

 Tylenol (analgesic)- 650mg (2 tablets), every 6hr. as needed daily

o Treats minor aches/pains
o Avoid hibiscus w/in hour of taking
o Vitamin C may increase drug bioavailability
o Liver toxicity can possibly be avoided with intake of milk thistle, N-acetyl-cysteine, and schizandra
o May cause nausea, loss of appetite
 Dulcolax (suppository)- 10mg, placed in rectum daily for constipation
o Stimulates bowel movements
o Depletes potassium with chronic use
o May cause nausea, vomiting, diarrhea
 Celebrex (nonsteroidal anti-inflammatory)- 200 mg capsule, 2x day
o Treats pain/inflammation
o Depletes potassium and sodium
o Eat high amounts of fruits and vegetables to replenish potassium
o Avoid white willow bark
o May cause diarrhea, indigestion rash
 Diovan (antihypertensive)- 160mg tablet, 1x day
o Treats high blood pressure/heart failure
o Do not take with meals
o May cause lightheadedness, headache, diarrhea, cold/flu symptoms
 Dilaudid (hydromorphone)- 1mg/ 2mg tablets daily, as needed
o Treats moderate to severe pain
o Use caution with 5-HPT, GABA, kava kava, California poppy, lemon balm, valerian and melatonin
supplements.
o Avoid high-dose calcium supplements to prevent constipation
o May cause lightheadedness, nausea, vomiting, dry mouth, constipation
 Heparin (injection, anticoagulant)- 5,000 unit/mL/day
o Helps prevent blood clots
o Interacts with vitamin K
o Limit vitamin E and alcohol intake
o Avoid garlic, ginger, ginkgo, ginseng, saw palmetto, green tea, and avocado.
o Caution with papaya, mango, and onions
o May cause abdominal pain, constipation, headaches
 Colace (stool softener)- 100 mg total, take 1 capsule 2 x day
o Treats constipation
o Depletes potassium and possibly magnesium
o May cause bloating, cramping, diarrhea
 Milk of Magnesia (antacid and laxative)- 2400 mg, 30mL by mouth daily as needed
o Treats constipation, upset stomach, and heartburn
o May reduce the absorption of dietary iron
o May cause lightheadedness and severe nausea and vomiting
 Reglan (gut motility stimulator, injection)- 10 mg total, 2mL IV every 6hr., as needed
o Treats GERD
o May interfere with nutrient absorption in the intestines.
o Take a MVI to avoid deficiencies
o May cause nausea, vomiting, diarrhea, headache
 Morphine (narcotic, syringe)- 2 mg total, 1mL every 2 hr as needed (IV)
o Treats moderate to severe pain
o se caution with 5-HPT, GABA, kava kava, California poppy, lemon balm, valerian and melatonin
supplements.
o Avoid high-dose calcium supplements to prevent constipation
o May cause nausea, vomiting, diarrhea, itching, dizziness
Melanie Daniel

 Zofran (5-HT3 antagonist, injection)- 4 mg total, 2mL IV every 6hr., as needed

o Treats nausea/vomiting
o Avoid ipriflavone
o May cause headache, fatigue, constipation, diarrhea
 Zosyn (antibiotic, injection)- 4.5 g total in D100mL every 6hr.
o Treats infection
o May cause vomiting, diarrhea, constipation, insomnia
 Vancomycin (antibiotic)- 1000 mg in NaCl, 0.9% 250mL IV every 12 hr.
o Treats infection
o Depletes folic acid, biotin and B complex vitamins and vitamin K. Also depletes some good bacteria in
intestines that support good digestion and immune function
o May cause low blood pressure, indigestion, hives, dizziness

5. Identify any labs directly related to the patient’s diagnosis (both medical and nutritional diagnoses)-Indicate if out of
range:

 High glucose (148mg/dL) = likely due to stress/infection

 Low H/H (10.1g/dL/31.2%), RBC (3.27), and High Plat. (615)= recommend MVI
 No S. Alb available since admittance to assess, would recommend checking.

6. Describe the progression of illness since admission (patient symptoms, medical tests, medical diagnoses, course of
illness):

 Pt arrived at St. Barnabas ED on 3/28 with chest pain (L) and muscle spasms. She was discharged with
antibiotics.
 Pt then arrived at Overlook the same day and was tachycardic and had leukocytosis of 14,000. While there, pt
was diagnosed with Staph infection (loculated L pleural effusion increasing in size and worsening atelectasis.
She was then discharged on 3/31 with antibiotics.
 Pt returns to Overlook on 4/1 with worsening symptoms and WBC count of 15,650. Pt has CT scan on which
reveals L lower lobe infiltrate and small L pleural effusion and R field atelectatic changes. Pt given antibiotics.
The CT scan was reviewed by a pulmonologist and determined the effusion to be too small to be tapped. PT
continued on antibiotics (Zosyn and Vancomycin), muscle relaxers and pain medications.
 Pt has a fever spike on 4/7.
 On 4/9, pt has another CT scan, without contrast, which shows moderate loculated L pleural effusion increased
in size from previous study and worsening L lower lobe atelectasis noted.
 Also on 4/9, pt undergoes CT-guided chest tube placement by interventional radiology, which showed bloody
pleural fluid, but negative cultures.
 Pt then has a trial of tPA and DNase, on 4/11, with minimal drainage noted from chest tube.
 On 4/13, a CT scan with contrast was repeated which revealed the loculated large L pleural effusion had
increased in size and worsening atelectasis on the L side. Cardiothoracic surgery MD spoke with MMC for pt to
possibly undergo a VATS procedure -> pt transferred to MMC for VATS procedure.
 Pt admitted 4/14 to MMC and has pigtail catheter in chest per RN notes.
 Per surgery note (4/14) pt to have L VATS decortication procedure on 4/15. Pt also diagnosed with loculated L
pleural effusion likely parapneumonic effusion and empyema.
 Pt POD#1 on 4/16, pt has chest tube to -20 serosanguinous and PICC line to go in today and DVT ppx HSQ to
also start today.

Nutrition Focused Physical Exam:

Fat Stores:
1. Orbital region: _X_ slightly bulging fat pads_________hollow, dark circles, loose skin
2. Triceps:(arm bent at 90-degree angle, roll the skin between fingers)_ X_at least 1 inch of tissue____little space
between fingers
3. Ribs/iliac crest: (Arms out in front, pressing against hands)_ X__ribs do not show, no protrusion of iliac crest
______Prominent ribs and iliac crest

Muscle Stores:
1. Temporalis:_ X_well defined muscle_____hollow
Melanie Daniel

2. Pectoralis:in a male_ X_ bones not visible____bones visible, in female_____bones slightly visible_____bones

protruding
3. Deltoid:_ X__rounded and curved______squaring of shoulders
4. Interosseous: (press thumb and forefinger together)_ X___muscle bulge_____ depressed area between thumb
and forefinger
5. Quadriceps/gastrocnemius:__ X__Well developed, well rounded_____concave depression/no muscle bulge

Edema: Monitor the length of time it takes for the area to rebound, longer time, more fluid retention
1. Fluid Accumulation:( apply pressure with thumb to ankles/feet for five seconds)_ X_ no
edema_____mild/moderate(1-2+pitting edema-15-60 seconds)_____Severe(3-4+ pitting edema up to 5 mins)

Assessment of skin, hair, nails, face and mouth:

Mouth: stomatitis Skin: dryness Nails: spoon-shaped Hair: thinness
cheilosis scaling pale dry
sores/candidiasis bruising brittle dyspigmentation
severe dental caries skin tears
shrunken tongue turgor
edema
pressure ulcers stage:__________ site(s): _________________

Assessment of Gastrointestinal function. Check all that apply:

□ History of aspiration □ Gastric outlet obstruction
Resolved: □ yes □ no □ Postoperative ileus
□ Swallowing disorder □ Bowel obstruction
□ Gastroesophageal reflux □ Short-bowel syndrome Remaining cm: ______
□ Esophageal obstruction □ Fistula
□ Delayed gastric emptying From__________ to __________
Output (vol.) ________________
□ Pancreatic insufficiency
(Adapted from: Renal Nutrition Forum 2017,vol 36,No 1)

Review of medical nutrition therapy and management for primary (or secondary) disease or disorder. (MUST BE
REFERENCED)

Heart Healthy Nutrition Therapy

A heart-healthy diet is recommended to reduce your unhealthy blood cholesterol levels, manage high blood pressure, and

lower the risk for heart disease.1

When following a heart-healthy diet it is important to eat a balanced diet that consists of whole grains, fruits and

vegetables, and lean protein sources. It is also important to choose heart-healthy unsaturated fats and limit the intake of

saturated fats, trans fats, and cholesterol. One should also achieve and maintain a healthy weight.1 Choose to prepare

more plant-based or vegetarian meals and use beans and soy foods for protein and that limit refined carbohydrate,

especially sugar and sugar-sweetened beverages, intake. It is also advised to eat more whole, unprocessed foods in
Melanie Daniel

order to eliminate the amount of sodium (salt) in the diet. And consume alcohol in moderation: one serving per day

(women) and two servings per day (men).

 One serving is equivalent to 12 ounces beer, 5 ounces wine, or 1.5 ounces distilled spirits

Choosing Heart-Healthy Fats

When reducing saturated fat intake, one can choose to consume lean protein and low-fat dairy foods.

Saturated fat is the biggest contributor to raised low-density lipoprotein (LDL) cholesterol levels in the diet and is

found in many plant-based foods, such as full fat dairy, red meats, and butter. Limiting saturated fat in ones’ diet has been

shown to significantly lower unhealthy cholesterol levels. Eat no more than 7% of your total calories each day from saturated

fat.1 Eating foods lower in fat and saturated fats are advised and have proven to improve cholesterol levels. These types of

foods include: skim milk and low-fat, non-fat dairy; lean meats (e.g. chicken); and vegetables oil (e.g. canola and olive oil).1

You can also try eating more plant-based or vegetarian meals.1

It is also important to avoid foods that contain trans fats increase levels of LDL-cholesterol. Hydrogenated fat in processed

foods is the main source of trans fats in foods.1 

 Trans fats are mainly found in stick margarine, shortening, processed sweets, baked goods, some fried foods,

and packaged foods made with hydrogenated oils.1

 Avoid foods with “partially hydrogenated oil” on the ingredient list such as: cookies, pastries, baked goods,

biscuits, crackers, microwave popcorn, and frozen dinners.1

Choose foods with heart healthy fats1:

 Unsaturated fats, polyunsaturated and monounsaturated fat, may help to lower blood cholesterol levels when

used in place of saturated fat in your diet.

 Dietary supplements with plant sterols and stanols can be taken to also help lower cholesterol level.

 Additionally, cholesterol intake should be limited to less than 200 milligrams per day.1

o Cholesterol is a substance carried through the bloodstream via lipoproteins, which are known as

“transporters” of fat. Some body functions need cholesterol to work properly, but too much cholesterol in

the bloodstream can damage arteries and build up blood vessel linings (which can lead to heart attack

and stroke).

o People respond differently to eating cholesterol. For individuals with high intake of dietary cholesterol,

different types of increase (none, small, moderate, large) in LDL-cholesterol levels are all possible.  
Melanie Daniel

o Food sources of cholesterol include egg yolks and organ meats such as liver, gizzards. Limit egg yolks

to two to four per week and avoid organ meats like liver and gizzards to control cholesterol intake.

Choosing Heart-Healthy Carbohydrates

Consume foods with viscous (soluble) fiber

 Viscous, or soluble, is found only in plant-based foods—animal-based foods like meat or dairy products do not

contain fiber. In the stomach, viscous fibers absorb water and swell to form a thick, jelly-like mass. This helps to

lower your unhealthy cholesterol

o Sources of viscous fiber include: asparagus, Brussels sprouts, sweet potatoes, turnips, apricots,

mangoes, oranges, legumes, barley, oats, and oat bran.

 Eat at least 5 to 10 grams of viscous fiber each day. As you increase your fiber intake gradually, also increase

the amount of water you drink. This will help prevent constipation.

 If you have difficulty achieving this goal, ask your RDN about fiber laxatives. Choose fiber supplements made

with viscous fibers such as psyllium seed husks or methylcellulose to help lower unhealthy cholesterol.

Limit intake of refined carbohydrates1

 Refined carbohydrates are foods with high amounts of simple sugars. They can raise triglyceride levels. High

triglyceride levels are associated with coronary heart disease.

o Some examples of refined carbohydrate foods are table sugar, sweets, and beverages sweetened with

added sugar.

Achieve and maintain a healthy weight.1

 Talk with an RDN or doctor about what is a healthy weight.

 Set goals to reach and maintain that weight. 

 Reduce calorie intake and increase physical activity to lose weight.

o A weight loss of 10 to 15 pounds could reduce LDL-cholesterol by 5 milligrams per deciliter.

 Talk with a health care team to learn what types of physical activity are best for you. Set a plan to get about 30

minutes of exercise on most days.

Reference:
1. Nutrition Care Manual. Nutrition Care Manual. https://www.nutritioncaremanual.org/. Accessed April 6, 2019.
Melanie Daniel

Documentation Section: Complete in the ADIME format:

ASSESSMENT:

Pt Hx: CM is a 48 y/o female admitted with chest pain and muscle spasms. Pt dx with L empyema s/p L VATS
decortication.

Current Diet Order: Regular

PMHx: HTN

Family Hx –
Mother- Alzheimer’s, DM, HTN, DVT, liver disease, autoimmune disease
Father- DM, heart disease

Anthropometrics:
HT: 5’1”
CBW: 83.9kg (185#)
BMI: 34.9 (Obese)
IBW: 48kg (110#)
% IBW: 168%

Biochemical Hx (4/1/19):
All labs WNL except:
 High glucose (148mg/dL) = likely due to stress/infection
 Low H/H (10.1g/dL/31.2%), RBC (3.27), and High Plat. (615)= recommend MVI

Albumin non available to assess- would recommend checking

Glucose 148mg/dL (70-100 mg/dL)- HIGH (likely due to stress/infection)
Hemoglobin 10.1g/dL (12-16g/dL)- LOW (recommend MVI)
Hematocrit 32.1% (36-47%)- LOW (recommend MVI)
RBC 3.27 x 1012 cells/L (4.2-5.9 x 1012 cells/L)- LOW (recommend MVI)
Platelets 615 x 109/L (150-350 x 109/L)- HIGH (recommend MVI)

NFPE:
Pt presented with no muscle mass or subcutaneous fat wasting.

Food and Nutrition Hx:

NKFA per pt. Pt reports poor-fair appetite/intake. ONS offered and pt agreeable. Pt attributes decreased intake 2/2 pain.
Pt complains of nausea 2/2 pain meds, but not vomiting- on Reglan/Zofran. (+) constipation- on Colace/MOM- encourage
increased fiber/fluid intake. (-) chewing /swallowing difficulty, however pt prefers softer food texture 2/2 recent procedure.
Pt will utilize room service.

Nutrition Risk:
Pt assessed at moderate nutrition risk due to poor-fair PO intake, IWL (6%) x 6 months, not significant, and BMI: 34.9
(suggests obese).

DIAGNOSIS:

1. Inadequate oral intake RT decreased appetite, nausea, increased pain, AEB intake less than or equal to
50% of meals.
2. Altered GI function RT pain meds, AEB constipation.

INTERVENTION:
Nutrition Prescription: Regular.

Goal: PO intake.
Melanie Daniel

Intervention: Pt to be given Ensure Enlive Vanilla BID.

Goal: Constipation to resolve.

Intervention: Encourage pt to increase fluid/fiber intake.

MONITORING and EVALUATION:

Indicator: PO intake
Criteria: Pt will intake >75% of meals.

Indicator: BM
Criteria: BM frequency.