Sage NCP Form

Patient: Nelson

Student Name: Meshal Samadzada Case: Upper GI

Referred for: Nutrition consult

NUTRITION ASSESSMENT
Food and Nutrition Related History: Had pre iousl! s "een e#periencing PM indigestion$ has increased indigestion on a regular "asis o er past !ear$ increased food%alcohol consumption attri"uted to stress$ &'( "eers )'*#%+ee,$ fried foods +orsen indigestion$ no pre ious nutrition'related education Anthropometric Measurements -ge: Gender Ht: 4t: 2565 ,g 8MI: *. /%0 M 123 4t H#: &1 ,g increase o er past 7 )&65 !rs Biomedical ata! Medical Tests " #rocedures 9a"s%:at -l"umin Glucos H"-& 8UN Creat Na; <; Hg" Hct MC= 0ther e e C &>%&5%&) N%&&> N%2 >65 &** *67 N%N%N%P-8: )($ Ca: 26&$ Cl: &>( Medical ia$nosis%Rele&ant 'onditions: Increased indigestion$ 0"ese Class I #ertinent Medications%Supplements%Her(s: -tenolol$ -spirin$ Multi itamin$ I"uprofen$ ?ums se eral times dail! S)in status:

Intact

Pressure Ulcer%Non'healing +ound@ Comments: +arm$ dr!

#atient%'lient%Family Medical%Health%'AM History: Assential H?N :# & !ear prior$ s%p R ,nee arthroplast! 7 !r prior$ famil! H# of C-: BfatherC Estimated Nutritional Needs Based on 'omparati&e Standards: Calories Protein Fluid &.*> ,cal%da! 5.'2. g%da! Current :iet 0rder Feeding -"ilit! 0ral Pro"lems # Independent N0NA Che+ing Pro"lem # 9imited -ssistance S+allo+ing Pro"lem A#tensi e%?otal -ssistance Mouth Pain # None of the -"o e No Nutritional :iagnosis at this time # Proceed to Nutrition :iagnosis 8elo+

&.*> oz6%da! Inta,e Good BD 57EC Fair Bappro#6 7>EC Poor BF7>EC Minimal G BF(7EC

NUTRITION

IA*NOSIS
A BAtiolog!C e#cessi e energ! inta,e as e idenced "!: A BAtiolog!CIIIIIIIIIIIIIIIIIIIIIIIIII II IIIIIIIIIIIIIIIIIIIIIIIIas e idenced "!: S BSigns H S!mptomsC 0"ese Class I$ o erconsumption of high'fat and energ!' dense food or "e erage$ and large portions of food S BSigns H S!mptomsC

P Bpro"lemC 0 er+eight%0"esit! related to: P Bpro"lemCIIIIIIIIIIIIIIIIIIIIIIIIII I IIIIIIIIIIIIIIIIIIIIIIIIIIIIrelated to:

INTER+ENTION
Recommended Nutrition Prescription: Fat'restricted diet B*> g%da!$ (>E of caloriesC$ recommended protein le el B5.'2. g%da!$ (>E of caloriesC Food or Nutrient :eli er!: N%Nutrition education: e#plain nutrition prescription recommendations for s!mptom management Bsaturated fatt! acid inta,e ersus total fat inta,e$ H8= proteinC$ portion control Nutrition Counseling: Self'monitoring and goal setting strategies Coordination of Care Brefer toC: N%GoalBsC: Patient +ill adhere to diet in order to promote +eight loss and pre ent e#acer"ation of s!mptoms

MONITORIN* " E+A,UATION

Indicators: Criteria:

4eight B1 monthsC

.. ,g BJ&>E +eight lossC