Patient: R.S.

Referred for: Healthv eatine/weieht loss

t
Food and Nutrition Related History: Patient referred by VENT fitness employee to help patient with general healthy eating and weight loss goals.
Patient has already started making significant changes to daily routine. Since April 2014, patient has cut but soda and
juice,
tried to eat "healthier"
and has been going to the gym for about 1 112 hours 6xlwk. Patient reports sometimes skipping meals, especially breakfast. Patient is concerned
about getting all necessary daily nutrients and would like to understand how to choose healthy meals/snacks without depriving self. Patient states
before making changes, ice cream, rice, and soda were "binge foods". Patient is mother to two 15-year-old sons and a 9-year-old daughter. The
children's request for certain foods such as whole dairy product and "junk" food influences own food choices. Patient states goal weight would be
130-1401b or to fit into a size 8 or 10 pants.
24-hr Recall:
Breakfast: bacon and lettuce on wheat Kaiser roll
AM Snack: appte w/ 1 tsp PB
Lunch: salad w/ hot sauce and sprinkled w/ spicy-flavored peanuts, 2 squares chocolate w/ almonds
Dinner: skipped
PM Snackr !/3 cup granola w/ diluted whole milk
Anthropometric Measurements
Age:38 Gender: Female Ht: 5'3" (63") Wt: 202.61b (92kg)
Wt Hx: 2391b (April 2014)
Wt change: 15% loss in 2 months -
significant
BMI: 35.89 (Obese)
Biomedical Data, Medical Tests & Procedures
Labs/Date I Albumin I Glucose HbAIC BUN Creat Na+ K+ Heb Hct MCV Other
n/a nla n/a n/a n/a n/a n/a n/a nla n/a n/a n/a
Medical Diagnosis/PMH/Relevant Conditions: non-smoker, no alcohol abuse
Fam Hx: heart attacks (father's side), diabetes, hypertension, heart attacks (mother's side)
Pertinent Medications: multi-vitamin (daily)
Skin status: X lntact
Comments:
! Pressure UlcerlNon-healing wound
Physical Assessment: nla
Estimated Nutritional Needs Based on Comparative Standards:
Calories: Mifflin St. Jeor x 1.5 activity factor
2763-3063kcal/day
Protein: 0.8-1.0e/kelday
74-929/day
Fluid: 30-35mllke/day
276A-322Ad/day
Diet Order:
Regular
Feeding Ability
X lndependent
C Limited Assistance
tr Etensive/Total Assistance
n N/A
Oral Problems
I Chewing Problem
tr Swallowing Problem
n Mouth Pain
X None ofthe Above
lntake
n Good
l>75%l
X rair (approx. 50%)
tr Poor (<50%)
n Minimal
-
(<25%l
tr NPO
tr No Nutritional Diagnosis at this time X Proceed to Nutrition Diagnosis Below
P (problem) Overweight/Obesity related to: E (Etiology): disordered eatinB patterns and
excessive energy intake as evidenced by:
S (Signs & Symptoms): patient reports of
skipping meals, binging on ice cream, rice, and
soda, and BMI of 35.89.
Nutrition Prescription: recommend energy medication: negative energy balance of 500-1000 kcal/day to provide 1763-2A63 kcaUday.
Food or Nutrient Delivery:
Meals and Snacks: 3 well balanced meals (approx. 500-600kcal each)
and 3 healthy snacks (approx 100-150kcal each) per day
Nutrition education:
ContentlApptication: Myplate, sample 2000kcal/day menus,
shopping/cooking tips for weight loss/management, ways to increase
fruit/vegetable consumption, portion size guidance, increasing whole
grainsfibers, limiting fat, choosing low-fat dairy products
2013 SGS DI
Nurition Counseling: eognitive-Behavioral Theory, Health Belief Model Ooordination of Care (refer to): n/a
oal(s): accomplish safe weight loss of 1-2lb perweek
lndicators:
wefft
I' A
Criteria:
1-2lb weight loss per weef
-. 1
,ttvtr t/ /,/\
4
Signature Preceptot',ie signature
2013
SGS DI