Name ARUSH Reason for Referral/Presenting Complaint/Diagnosis:…
Name ARUSH Reason for Referral/Presenting Complaint/Diagnosis:…
Name | ARUSH | ||
Reason for Referral/Presenting Complaint/Diagnosis: | WEIGHT LOSS | ||
NUTRITION ASSESSMENT | |||
Age: | 24 | Height: | 5’8 |
Weight: | 185 | BMI: | 28.1 |
Food/Nutrition-Related History | |||
Number of servings:
8oz-eq starches, 3 veg, 2 fruit, 3 milk, 6.5oz meats, 7 fats, and 362 other Cho. Energy intake 3,312.5 kcalories. Protein intake 115 grams/day or 13.8 % of kcalories Total fat intake ~ 121.5 grams/day of total fat or 33.0% of kcalories from fat. Carbohydrate intake 1,133 grams/day or 34.2 % of kcalories. Micronutrients of concern: vitamin C, A and complex B; Calcium, Iron and Potassium Physical Activity: 0 min of moderate or vigorous activity per (day, week) Other physical activity concerns: walking outside to take the bus and walking to the classroom |
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Anthropometric Measures | Client History | ||
Recommended BMI 18.5 – – – 24.9 kg/m2
IBW 150.8 | % IBW 122.52 UBW 150 | % UBW 123.33 Recent wt changes: 35 lbs in the past 6(months or year). Weight Status: Overweight. Arush’s current weight is 185 lbs, which is 35 lbs above his usual weight of 150 lbs. This significant weight gain is a concern.
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Personal:
Medical:
Social:
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Knowledge, Beliefs, and Attitudes | Medications/Supplements | ||
Arush believes in the benefits of both Ayurvedic and Western medicine. He follows a daily routine that includes prayer and meditation. Does not consume alcohol or smoke. | No medications / Supplement: Ginseng, Echinacea, Gingko, and Aloe Vera. | ||
Standards (Recommendations) | |||
Energy Needs: (9.99 x Weight [83.91]) + (6.25 x Height [172.72]) – (4.92 x 24) + 5 = 1804.57.
Protein Needs: 102 to 178.81 grams Food Group Needs: using 1,800 kcal recommendation: fruits 1.5 cups, vegetables 2.5 cups, grains 6oz-eq, meat and beans 5oz-eq, milk 3 cups, oil 5tsp and discretionary calorie allowance <195. AMDR for Carbohydrate: 229.9 to 332.09 g per day AMDR for Fat: 45 to 79 g per day Physical Activity Recommendations: Arush should be encouraged to incorporate more physical activity into his daily routine, as he currently has limited physical activity approximately 150 minutes. |
Let’s try to diagnose our patient’s problems. A: Identifying the Problem: the “P” in PES Step 1: Review the Nutrition Assessment Questionnaire and the MyPlate Form. Step 2: Write down all the nutritional problems of the client in the column labeled problem. You may include physical inactivity (if it is a problem). Problem Threat to Short-term or Long-term Health Priority (1 to 5) Nutrition Diagnostic Term Physical inactivity Little whole grains Too many calories in added sugar Step 3: In the column marked “threat to short-term or long-term health,” list the short-term and long-term problems that could occur if your client continues to eat in this manner. Step 4: Prioritize the problems from 1 to 5 (1= the greatest threat to your client’s short-term or long-term health and 5= the least threat). Step 5: Look at the Nutrition Diagnostic Terms in the IDNT textbook or eNCPT. Select a diagnostic term for each of the problems. You may need to look at the definitions. List the possible terms you could use for each problem in the column labeled “nutrition diagnostic term.” B: Identifying the Etiology: the “E” in PES Step 6: In the table on page 2, write down the 3 top priority “Nutrition Diagnoses Terms” from steps 1 to 5 in the column entitled Diagnosis Term. Step 7: Write down your client’s personal reasons for the nutritional problems. You may need to look at the generic reasons for why a nutritional problem would occur within the definitions for each problem in the IDNT textbook (4th ed) or eNCPT. These reasons are the E or etiology of the diagnosis. Your planned intervention should focus on the E. Determinants Diagnosis Term Food-Related Person-Related Social & Environmental Economic Information • Food-Related Determinants could include taste, food preferences, biological cues such as hunger/satiety, early experiences with food (exposure, social modeling, parenting practices, food used as reward). • Person-Related Determinants could include perceptions and beliefs about food, lack of motivation to change, individual knowledge and skills (cooking, grocery shopping, time management, coping with stress), and cultural norms. • Social and Environmental Determinants could include food availability and accessibility at school, work and home or social support for dietary change. • Economic Determinants could include income and cost of items. • Information Determinants could include media influence and nutrition knowledge. C: Identifying the Signs and Symptoms: the “S” in PES Step 8: List the signs or symptoms (or the evidence) that led you to your top 3 nutrition diagnoses. This portion of your diagnosis statement should include quantities that are compared to established standards. Nutrition Diagnosis Current Intake, Labs, Anthropometrics (Quantity) Recommended (Quantity) Part D: Putting it all Together: The Nutrition Diagnosis Statement The nutrition diagnosis is written in the following way: • Problem (using the diagnosis terms only) related to (R/T) the Etiology as evidence by (AEB) the signs and symptoms. Step 9: Now, write your 3 nutrition diagnoses for your patient in the proper format. Diagnosis 1: Diagnosis 2: Diagnosis 3: Case Study Part B: Nutrition Diagnosis Assignment After reviewing the nutrition assessment for your case from module 6, complete the nutrition diagnosis worksheet to help you develop three diagnoses for your client. Now, write 3 nutrition diagnoses for your patient in the proper format. You will receive 5 points for each correct diagnosis. Your diagnosis statements will be graded based on the following criteria: • 1 point for appropriate P; • 1 point for client specific E; • 2 points for two appropriate S/Sx with comparative standards, and • 1 point for correct format. Diagnosis 1: Diagnosis 2: Diagnosis 3: