ADIME Nutrition Documentation Form



ADIME Nutrition Documentation Form Section: Thursday

Name: Jonny Wymore

Nutrition Note: Case Study 9 Date: 4/08/2013 Time: 0800

A: Nutrition Assessment (Assessment info related to Nutrition Dx)

|Client Hx |Nutrition-Focused Physical Findings |Anthropometrics |

| | | |

|Name: Jack Nelson |Obese |Ht: 5’ 9” |

|Age: 48 |Chronic and consistent indigestion over the past year |Wt: 215 lbs |

|Male | |BMI: 31.7 kg/m2 |

|Causasion | | |

|Pt Hx: Hypertension 1y | | |

|Family Hx: Father had CAD | | |

|Food/Nutrition-Related Hx & Comparative Standards |Biochemical, Medical Tests & Procedures |

| | |

|Gained 35lbs in the last 5 years |CHOL 200 mg/dL (H) |

|Food intake: increased food intake over the past year related to stress |HDL-C 20 mg/dL (L) |

|Medicine: Atenolol 50mg/d, Aspirin 325mg/d, daily multivitamin, Ibuprofen 500mg 2x/d for the last |LDL 165 mg/dL (H) |

|month |TG 178 mg/dL (H) |

|Energy intake: 4,360calories | |

D: Nutrition Diagnosis (PES statement)

1) Food and nutrition-related knowledge deficit of GERD-specific diet, related to habitual consumption of foods which increase gastric acidity and lower GES pressure, as evidenced by dietary recall containing high fat foods, soda, and alcohol.

2) Obesity related to excessive energy intake of 150% of daily caloric needs, as evidenced by 24-hour recall of 4,360 calories compared to his needed 2,900.

I: Nutrition Intervention

Prescription:

PES #1

Goal: Increase nutrition-related knowledge to decrease a) foods that increase gastric acidity, and b) lower GES pressure.

Intervention: Restrict foods that increase gastric acidity and lower GES pressure, including soda, alcohol, caffeine, and high fat foods.

PES #2

Goal: Weight loss

Intervention: Prescribe a 2,500 calorie diet, and provide nutrition education on new GERD diet as well as making healthful dietary choices using the TLC eating plan.

TLC diet: ................
................

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