Patient:

ert fr!l!_-'rn-,
?-

Referred for:
x'r:ta t r'\,t' ?,:'l

Food and Nutrition Related History: Pt reports having an increased appetite since admission. Pt has progressed from FL|Qto 2100 ADA diet. Pt ate couple bites of scrambled egg and some home fries for breakfast this morning (aprrox 30% of meal). Pt denies any chewing/swallowing difficulty. Pt's states intake has been down since starting chemo treatments for lung CA and with recent abd pain and N/V. At home pt typically eats toast w/ PB for breakfast, sandwich for Iunch, and some variety of meat/pot/veggie, pasta, casserole, soup/stew for dinner. Pt admits to snacking on junk food such as potato chips, cookies, snack cakes, etc. Pt lives alone and does own shopping/cooking. Pt checks blood sugars at

home;usuallyl4O-200. Ptdoesnotfollowanyspecial diets. Pthasnothadanydifficultyw/sideeffectsfromchemotreatmentsuntil

aware of 15lb wt loss over last 2 months. Pt agreeable to supplementation. Anthropometric Measu rements Wt: 2051b (bed scale) Ht: 62" Age: 62 Gender: Female

now.

Pt

BMI:37.49-Obese

Wt Hx: 15lb wt loss % Wt change: 7%in2 monthssisn if ica nt

Biomedical Data, Medical Tests & Procedures H bAlC La bs/Date Albumin G lucose

BUN

Creat
1.3

Na+

K+

Heb

Hct

MCV 87.6

03/tl/t4

2.9

r,

87

9,0t

22+

143

4.6

8.3.,

26.2.t

Other cHoL 2s3t

TRIGL
Ca

265f

8.0.f 7s.61

WBC 5.77
NEU

Abs. Lymph

1.0.l,

Medical Diagnosis: Obstructive Ureteral Calculus; N/V, abd pain, constipation x3 days
PMH/Relevant Conditions: Stage lV lung cancer (on 3'd round of chemo treatment-goes every 3 weeks), DM 2, hyperlipidemia, COPD (02 dependent), sleep apnea, smoker Fam Hx: father-colon cancer, siblings-lung cancer Pertinent Medications: Coumadin, Spiriva, Zocor, Albuterol, Glyburide, Symbicort, Lisinopril, Levemir, Lasix, Zoloft, Tramadol
Skin

status: X lntact n

Pressure Ulcer/Non-healing wound; Comments: warm, dry, normal capillary refill

pbreathing;nowheezes,rales,rhoni,Cardiovascular:WNL,Abdomen:soft,Lsidetenderness,
non-distended, no rebound /guarding, Neurological:awake, alert, oriented x3 Estimated Nutritional Needs Based on Comparative Standards: Protein: 7.z-Lselkgl day Calories: Mifflin St, Jeor x 1.5 activity factor 772-L40e/day 2165-2465kcal/day Diet Order: 2100 ADA Diabetic
Feeding Ability

Fluid; 30ml/kg/day

2.8t/day
I

Oral Problems

nta ke

X I n
N

lndependent Limited Assistance Extensive/Total Assistance

N/A

I ! n X

Chewing Problem Swallowing Problem

Good (> 75%)

Fair (approx.SO%l Poor (<50%)
NPO

Mouth Pain
None

tr X tr

ofthe Above

D Minimal -(<25%\

No Nutritional Diagnosis at this time M**3'**'{ {3 W * k* {\tr {}%l li P (problem) Unintentional weight loss (NC3.2I related to:

Proceed

to Nutrition Diagnosis Below

& Symptoms): 75lb (7%\ wt loss in 2 months-sisnif icant. S (Signs & Symptoms)
S (Signs

E (Etiology) increased nutrient needs secondarv to catabolic illness as evidenced bv:

E

(problem) lated to:

(Etiology) evidenced by:

e*47*"W\tX?,iTn*?4

betic diet to provide 2765-2465kca1,2409 CHO, 712-1409 pro, 2.81fluid/day Nutrition education: Application(E-2): Chemo side effect management - small, frequent Meals and Snacks (ND-1): 2100 ADA diabetic diet meals, limit fluid intake at meals, supplement and nutrient-dense food Medical Food Supplements (ND-3.1): Glucerna TID (660kcal, 60g CHO, options at home, taste alterations, N/V/D and constipation pro) 30g solutionslrelief, Diabetes management-CHO counting, label reading Coordination of Care (refer to): N/A Nutrition Counseling: N/A

Nutrition Prescription: Recommend Food or Nutrient Delivery:

21OO ADA dia

Goal(s): Pt

to consistentlv meet estimated needs to arrest further wt

loss.

2013

SGS DI

MONITORING & EVAIUATION

wel

lndir tors: rt

Criteria: Pt maintains wt within 1-2lbs

A Alu

,/,

't\(. Precepto/s signature

il',1 q
.-..t.
Date :,

s Signature

201.3

SGS DI