Nutrition Care Plan

Nutrition Assessment & Care Plan Zachary Wong
1. Dietary Intake
a. 24 Hour Recall
Food Item Quantity/Portion Preparation Calories Fat Protein Carbohydrates

Size Method (kcal) (grams) (grams) (grams)
Cereal (Special K 1 Bowl, 1.5-2 With milk 165 2.58 g 4.74 g 49.56
w/ Vanilla & cups kcal
Almonds
Non Fat Milk 1.5 cups Poured into 137 0 11.99 g 18
cereal kcal
Mixed Fresh 1 cup Fresh and cut 133 3.75 g 0 36.01 g
Fruit kcal
(Blueberries,
pineapple,
strawberries,
oranges)
Turkey Sandwich 1 full sandwich Prepared at 390 12 g 30 g 41.01 g
(avocado, home kcal
lettuce, wheat
bread, honey
mustard)
Fuji Apple Small Raw 80 kcal 0 .49 g 22.01 g
Water H20 Filtered 0 0 0 0
water in
reusable
bottle
Salmon 10 oz filet Prepared at 599 42 g 47.99 g 1.99 g
home kcal
Pasta with 1 cup Prepared at 310 5g 11 g 52 g
mushroom home kcal
bacon sauce
Mixed Steamed 2 cups Steamed at 53 kcal 0 1.5 g 3g
Vegetables home
(broccoli,
carrots, snap
peas, spinach)
Roasted ½ oz Store bought 85 kcal 3.5 g 3.5 g 10 g
unsalted
Pumpkin seeds
Water 64 oz Filtered 0 0 0 0
water
Totals 1952 68.83 g 111.21 233.58 g
kcal g
b. Questionnaire: Questionnaire in Lee text is not very informative as it only goes through
liquids and fruits in diet. Doing a short internet search provides the full questionnaire,
however, was unable to have Pt complete full questionnaire. From the information
given, it seems fairly accurate as Pt only really consumes water throughout day and
most of the year. His other beverage choice is milk and chocolate milk, which he
consumes once or twice a month; and soft drinks maybe six in a year.
c.
2. Anthropometric Measurements
a. Height: 6’ or 72 inches or 182.88 cm or 1.83 m
b.Weight: 208 lbs or 94.5 kg
c.BMI & category 94.5/1.83=51.64/1.83= 28.2, Overweight
d.IBW 18.5x3.35= 61.98 kg=136 lbs. 24.9x3.35= 83.415 kg=183.51 lbs.
e.%IBW 152%-113%
f.UBW 200 lbs
g.%UBW (100x208)/200=104%
h.Frame Size 182.88cm/19 inches=9.63 At the border between medium to large framed
i.Waist Circumference: 39.1 inches
j.Estimated % Body Fat: The book is unfortunately not accurate in this situation as it stops
at 18 years of age: 25-30% from 103 mm sum. From http://www.health-calc.com/body-
composition/skinfold-d-and-w, it puts the percentage for a 57 year old at 37.8 percent
body fat.
i. Biceps: 15 mm
ii. Triceps: 22 mm
iii. Subscapular: 34 mm
iv. Suprailiac: 32 mm
k. Nutrition Focused Physical Exam
i. After running both exams from Krause and Lee texts, Pt did not exhibit any of
these factors. No signs of edema, malnutrition, loss of muscle mass or
subcutaneous fat mass. Pt, is overall in very good health other than some
underlying factors like high blood pressure and high cholesterol.
3. Estimated Needs
a. Energy Needs
i. (57 years old, 72 inches (1.83 m), 208 lbs. (94.5 kg), low active physical activity
level
662-9.53x57+1.11[15.91x(94.5)+539.6x(1.83)]=662-
543.21+1.11(1503.5+987.47)=119+2764.98=2883.98 kcal
ii. REE: 10(182.88 cm)+6.25(72)-5(57)+5 = 2297.55-285+5=2017.55 kcal
iii. TEE: 1086-10.1x57+1.12[13.7x(94.5)+416x(1.83)]=1086-
575.7+1.12[1294.65+761.28]=1086-575.7+2302.6=2812.9 kcal
b. Protein Needs
i. 0.8 g/kg = 0.8x94.5=75.6 g of protein
c. Fat and Carbohydrate Needs
i. Fat: 20-35% .20x2883.98=576.8kcal .35x2883.98=1009.4 kcal
1. 577-1009.4 kcal from fat
ii. Carbohydrate: 45-65% .45x2883.98=1297.8 .65x2883.98=1874.6
1. 1297.8-1874.6 kcal from carbs
4. Biochemical Assessment
a. Fasting blood glucose: 132 mg/dL
b. Hemoglobin: 14.2 g/dL
c. Hematocrit: 46%
d. Cholesterol: 223mg/dL
e. Triglycerides: 182 mg/dL
5. Medical History
a. High blood pressure
b. High Cholesterol
c. History of myocardial infarction in immediate family (father, sister, brother)
6. Nutrition Care Process Worksheet
NUTRITION CARE PROCESS - PATIENT CARE WORKSHEET
NUTRITION ASSESSMENT: (1-2 paragraph summary containing pertinent data from each section of the
assessment; i.e. dietary intake, anthropometrics, and biochemical data)
Pt is 57 years old male with a height of 72 inches and a weight of 208 lbs with usual body weight of 200 lbs,
Pt has had eight pound weight gain within past year. Pt works as a logistics manager at a department store,
and is on his feet a lot of the day. When Pt is home with wife, he goes out walking for about 30-40 minutes a
day. Other than that Pt doesn't get much other physical activity throughout the week. He has a BMI of
28.2, overweight category and a frame size of medium to large. Pt waist size is 39.1 inches, getting close to
an unhealthy waist size. Estimated body fat percentage is 37.8 percent. Biceps measurement is 15 mm,
Triceps 22 mm, subscapular 34 mm, suprailiac 32 mm. Currently consumes about 1952 kcal as according
to 24 hour recall. Usually consumes cereal with milk in morning, a turkey sandwich with veggies at lunch,
and various homemade dinners at home. Mostly drinks water throughout day and does not consume
alcohol. Has high blood pressure and high cholesterol which Pt takes medication for. Pt also has immediate
family history of myocardial infarctions.
Biochemical Assessment:
Fasting blood glucose: 132 mg/dL
Hemoglobin: 14.2 g/dL
Hematocrit: 46%
Cholesterol: 223 mg/dL
Triglycerides: 182 mg/dL
NUTRITION DIAGNOSIS: (Problem, Etiology, Signs/Symptoms Statement)

Altered nutrition-related laboratory values in regards to high cholesterol as evidence by lab value of 223 mg/dL
Altered nutrition-related laboratory values in regards to Diabetes mellitus (type 2) as evidenced by lab value of
132 mg/dL.
Describe your reasoning behind selecting the above nutrition diagnosis: (2-3 sentences)
The reason I chose this PES statement was because generic lab values has patient with Cholesterol levels with a higher
than 200 mg/dL. The patient that the nutrition care plan was on, does indeed have high cholesterol and is currently
taking medication for it.
The second PES statement is because the lab value is so high that the generic patient has Type 2 diabetes.
NUTRITION INTERVENTION: (Recommendations and plan; i.e. dietary changes, referrals to other
disciplines, educational needs etc.)
Lose weight to return back to UBW
Monitor BP and Cholesterol so Pt can lower both
Continue taking BP and Cholesterol meds
Pt needs to increase activity level to at least 3 times a week for at least 45 min to 60 minutes a day
Educate Pt and Pt's sprouse on various physical activities best suited for Pt.
Provide Pt with recommended personal trainer contact information
Recommend changing diet, away from processed foods like lunch meat. Provide education on whole foods.
Have Pt continue to drink water, maybe increase water consumption throughout day.
Generic patient readings:

Educate Pt and Pt's spouse about Type 2 Diabetes
Start patient on medication for Type 2 Diabetes
MONITORING/EVALUATION: (Specific and measurable ways you plan to assess the effectiveness of your
intervention)
Continue to have patient keep dietary log, to make sure they stay on tract
Have patient keep a log of physical activity for the week
Follow up in 6 months to see if patient is making strides in lowering fat%, BP, and cholesterol. Also weigh patient to
see if they are close to their UBW.
Reevaluate Pt's lab levels, including FBG level.
7. Reflection
a. Since already having rapport with the Pt, the questions being asked were not
uncomfortable and I was given full and honest answers. Pt was very open about what
they consume in a given day and gave the questionnaire thought. Pt was a little uneasy
about the skin calipers, however, when told patient could wear a short sleeve shirt and
didn’t need to pull it all the way off it was easier. I am mostly confident, it has been a
while since I did skin calipers to be honest and those measurements might not be 100%
accurate. Some changes I would make would probably be to relearn how to collect skin
caliper data and to learn more appropriate phrases to explain the collection of that
data.

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Nutrition Assessment & Care Plan Zachary Wong

Food Item Quantity/Portion Preparation Calories Fat Protein Carbohydrates

NUTRITION DIAGNOSIS: (Problem, Etiology, Signs/Symptoms Statement)

Generic patient readings:

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