Figure B-5 Sample Nutrition Chart Form Using A-D-I-M-E …



MNT I

Nutrition Care Process Project

Student’s Name: Elona Sevo Patient/Client’s Initials: Mr. J

ASSESSMENT: Summary of subjective and objective data from chart review and patient/caregiver.

Pt’s age:53 Male/Female Dx: H. Pylori Infection Medical Problems/PMH:

Duodenal ulcer, acid reflux after meal

Ht. Current Wt UBW/%UBW IBW range /%IBW WC* BMI

|5’8” |203 |188lb/108% |154lb./131% |98 cm. |30.9 |

|Interpretation of wt. status: |

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|Based on patient’s BMI and %IBW they are in the obese category. There is no concern for waist circumference as it is under 40”. |

|Patient has an 8% increase in body weight in the past three months. |

*WC – Waist Circumference

|Estimated energy needs (note equation used): (Harris-Benedict) |Estimated protein needs (note g/kg): |

|66.5+13.8(92.2kg) + 5.0(172.72cm) – 6.8(53 yrs.) |Protein 20% |

|1843 cal. * 1.2 = 2212 |At 1.00 g/kg (92g of protein) |

|Estimated CHO/Fat needs: |Fluid needs (note equation used): 25-55 yrs. Old (35 |

|Fat 30% (61.4g) |mL/kg) |

|CHO 50% (230g) |35(92.2) = 3227 |

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|D. Dietary Adjustments: 5 points |

|Overall what type of changes in Mr. J’s diet would you recommend? |

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|Some recommendations for Mr. J would be a lower calorie consumption, lower carbohydrate intake to around 230 grams, lower fat |

|consumption to about 60 grams, increase fluids to 3.2 Liters, increase vegetable intake, increase vitamin and mineral intakes such |

|as potassium and vitamin D, avoid alcohol use. |

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|Make adjustments to his diet to help him lose weight and manage his GI symptoms. |

Diet History (24 recall): Adjustments to diet:

|Breakfast: |Add protein such as an egg and cut coffee to 1 with 1 |

|1 medium banana, |packet of sugar. |

|2 large coffees with 2 packets of sugar | |

|Lunch: |Replace cola with a vitamin D fortified orange juice or |

|1/4 lb. cheeseburger (no bun), |water, and instead of fries add sides of salad and whole|

|1 medium (1/2 cup) French fries with 4 pkts ketchup, |grain bread. |

|12 oz. regular cola | |

|Afternoon Snack |Switch crackers to whole grain crackers or fruit to |

|2 oz. cheddar cheese |accompany the cheese. Switch iced tea to a cup of |

|6 saltine type crackers |fortified milk. |

|8 oz. sweet iced tea | |

|Dinner |Switch to brown rice or quinoa and a side of mixed |

|1 cup instant white rice with 2 tsp butter |steamed vegetables. Could also add a protein with the |

|1 cup corn or peas |brown rice such as 3 oz. of chicken breast and cut brown|

|4 oz. fried shrimp or chicken |rice to 2/3 cup. Use cayenne pepper instead of hot sauce|

|1 Tablespoon hot sauce |to cut Na. Replace alcohol with water. |

|12 oz. regular beer | |

|Snack: |Switch to a Greek yogurt with vitamin D and protein and |

|6 oz. fruit yogurt, |add fresh fruit on the side. |

|1 oz. walnuts | |

|16 oz. water | |

List medications; implications and nutrition related side effects in the chart:

|Medication |Implication (mechanism of action) e.g. |Nutrition side effects and |

| |Lasix – diuretic |Contraindications (such as alcohol): |

| | |Factors that can affect nutrition intake, |

| | |GI, vitamins, minerals and labs. |

|Tetracycline |Antibiotic |Take 1 hr. before or 2 hrs. after |

| | |food/milk. Ca, Fe, Mg, Zn or MVI minerals, |

| | |antacids and fortified foods to be taken |

| | |3hrs. before or 1 hr. after drug. |

| | |Nutrition- Anorexia, chelate formation with|

| | |Ca, Fe, Mg, or Zn. May lower vitamin K. |

| | |Possible vitamin B deficiency. Increased |

| | |risk of benign intracranial HTN with |

| | |vitamin A supplement. Decreased skeletal |

| | |growth in children. |

|Metronidazole |Antibiotic, Amebicide, Antitrichomonal |Taken orally or IV. Take with meals to |

| | |lower GI distress, but food decreases drug |

| | |bioavailability. |

| | |Diet- low sodium recommended |

| | |Nutrition- Anorexia |

| | |Oral/GI- Dry mouth, stomatitis, metallic |

| | |taste, epigastric distress, diarrhea, |

| | |constipation |

| | |S/Cond: Avoid all alcohol during use and |

| | |for three days after. Increased risk of |

| | |dental problems. |

| | |Blood/Serum: lowered TG, |

|Bismuth Subsalicylate |Anti-diarrhea & Nausea |Constipation, high or low uric acid, |

| | |decreased potassium |

|Omeprazole |Anti-ulcer, anti-gerd |Can be taken orally or IV. |

| | |Drug-for optimal effect take 30-60 minutes |

| | |before meal. |

| | |Diet: may lower Fe, B12, and Ca absorption.|

| | |Ca supplement advised. Avoid gingko. |

| | |Oral/GI- decreased gastric acid secretion, |

| | |increased gastric pH, nausea, abdominal |

| | |pain, diarrhea |

| | |S/Cond: avoid alcohol |

| | |Blood/Serum: decreased B12 possibly, |

| | |increased cholesterol, increased glucose |

|Advil |Antriarthritic, Analgesic, NSAID |Take with food or milk to avoid GI |

| | |irritation. Limit caffeine. Avoid or limit |

| | |garlic, gingko, ginseng, ginger, horse |

| | |chestnut. |

| | |Nutr: can decrease appetite |

| | |Oral/GI: bloating, diarrhea, constipation |

| | |S/Cond: Avoid alcohol |

| | |Blood/Serum: High K |

|General assessment: Client must avoid all alcohol for the next 7-10 days and be very cautious thereafter while taking Omeprazole |

|and Advil. Also, for the next 7 days while on Metronidazole client should remain on a low Na diet. To avoid GI distress the |

|Metronidazole should be taken with food and caffeine limited with Advil. Monitor B12, cholesterol, glucose, and potassium. |

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List abnormal labs and interpret in the chart:

|Abnormal Laboratory |( or ( |Reason for Abnormality |Nutritional Implications (what should be done |

|Test | | |nutritionally to correct the lab – if applicable) |

|Potassium |Low |Low potassium in diet and taking |Consume more Potassium in diet |

| | |Tetracycline and Bismuth Subsalicylate that| |

| | |may lower K | |

|HbA1c |High |High consumption of carbohydrates and |Keep CHO consumption at around 230g. |

| | |taking Omeprazole that may increase glucose| |

|HDL-C |Low |Sedentary lifestyle |Increase exercize |

|Triglyceride |High |Meals high In saturated fats |Switch to healthier fats |

|General assessment: Potassium intake should be at 4700 mg., especially when taking Tetracycline and Bismuth Subsalicylate. |

|Carbohydrate consumption should remain consistent at around 230 g. and client should increase exercise to increase HDL-C. Also, |

|Triglycerides at 270 put patient in high risk category and should be decreased by limiting saturated fats. |

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NUTRITION DIAGNOSIS:

Problem Etiology (related to) Signs and Symptoms (as evidenced by)

P-E-S Statement:

|Excessive energy intake related to food and nutrition related knowledge deficit concerning energy intake as evidenced by intake of |

|energy in excess of estimated or measured energy needs. |

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PES Statement:

|Less than optimal intake of healthy fats related to food and nutrition related knowledge deficit concerning types of fats as |

|evidenced by triglycerides higher than 150 mg/dL. |

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|MEASUREABLE GOALS |INTERVENTION |

|Goal 1: Reduce weight to 191 pounds in the next three months |Plans for Goal 1: Reduce calorie intake by 500 calories. Educate |

| |client on adding vegetables and healthy carbohydrates to diet. |

| |Educate client on replacing high sugar drinks with healthier, |

| |nutrient dense fluids. |

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|Goal 2: Reduce triglycerides to 150mg/dL or less at next blood |Plans for Goal 2: Educate client on the difference between |

|test. |saturated and unsaturated fats. Provide client with a list of |

| |fats he can use as a replacement for saturated fats in his diet. |

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I. MONITORING and Evaluation: 2 points

Identify what will be used to monitor and evaluate the effectiveness of the intervention:

__X___Weight _____food intake at meals __X___Labs (specify) _____Other

Weight will be checked for increase or decrease to see if intervention has been effective. Also, labs will be checked for

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A. Weight status: 3 points

B. Estimate nutrient needs: 4 points

C. Nutrient analysis of diet recall: 4 points

Analyze diet recall using diet analysis software and summarize your report here: Report Kcal, g Protein, CHO, Fat and report any vitamins or minerals not meeting needs: Do not attach your diet recall report – include summary – e.g., what percent of vit/min is pt getting compared to RDA; 52% Calcium, 30% Vitamin C.

Based on Mr. J’s 24 hour recall Sodium: 204%

Calories: 2970 Biotin: 28%

CHO: 380g (50.8%) Vitamin C: 44%

Protein: 95g (12.7%) Vitamin D: 2%

Fat: 111g (33.5%) Vitamin E: 28%

Fluid:1.3 L Vitamin K: 56%

Potassium (42%) Chromium: 5%

Flouride: 4%

Iodine: 22%

Magnesium: 54%

Based on a 24-hour recall, client is consuming excessive calories, including fat and carbohydrates. He also has an intake of only 40% of recommended fluids and has a low consumption of Potassium, Biotin, C, D, E, K, Chr, Fl, I, and Mg. Na intake is at 204% of the daily recommendation.

E. Meds: 5 points

F. Labs: 5 points

G. PES: 4 points

H. Goals/ 4 points

Intervention: 4 points

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