SageDietetic Internship - NCP Form

Patient: C Referred for: Inability to takePO

NUTRITION ASSESSMENT
Foodand Nutrition Related History:
This patient has been on TFs since2008 dueto low body weight and lack of interest in eating. Shetolerates themwell and takes pleasurefeeds
fromspoon of nectar thickened liquids when desired.
Anthropometric Measurements
Age: 54 Gender F Ht: 56" Wt: 45.6 kg BMI:23WNL
Wt Hx: 47 kg
%Wt change: 2.4%not significant
Biomedical Data, Medical Tests& Procedures
Labs/Date Albumin Glucose HbAlC BUN Great Na+ K+ Hgb Hct MCV Other
7/13 3.1
gm/dl 4/
n/a n/a n/a 0.26
mg/dl 4^
Medical Diagnosis/PMH/Relevant Conditions:
Microcephaly, MR, Epilepsy, Scoliosis, Spastic quadriplegia, CP, osteoporosis
Pertinent Medications
Lamictil
Centomin
CalciumCarbonate
Binosto
Miralax
Milk of Magnesia
Skin status: X Intact PressureUlcer/Non-healingwound; Comments;
Physical Assessment:
Estimated Nutritional NeedsBasedon Comparative Standards: 45.6 kg
Calories
1048-1140 (23-25 kcal/kg quadraplegics)
Protein
36g/day (0.8 g/kg)
Fluid
1410 mL/day (30 ml/kg)
Diet Order
Jevity 1.0 at 100 mL/hr x 10 hrs via
g-tube
Pleasurefeeds, nectar-thickened
liquids
FeedingAbility
Independent
Limited Assistance
Xa Extensive/Total Assistance
N/A
Oral Problems
ChewingProblem
SwallowingProblem
Mouth Pain
XQ Noneof theAbove-
Periodontal disease
Intake
Good (>75%)
Fair (approx. 50%)
Poor(<50%)
Minimal-(<25%)
NPO
-Pleasurefeeds PO
No Nutritional Diagnosis at this time X Proceed to Nutrition Diagnosis Below
NUTRITION DIAGNOSIS
P (problem) Swallowingdifficulty E(Etiology) neurological causes S(Signs & Symptoms)
SLP evaluation
Coughing, choking, aspiration upon swallowing related to: as evidenced by:
S(Signs & Symptoms)
SLP evaluation
Coughing, choking, aspiration upon swallowing
S(Signs & Symptoms)
SLP evaluation
Coughing, choking, aspiration upon swallowing
P (problem) E(Etiology) S(Signs & Symptoms)
related to: as evidenced by:
S(Signs & Symptoms) S(Signs & Symptoms)
INTERVENTION
Nutrition Prescription:
Jevity 1.0 at 100 mL/hr x 10 hours viag-tube. Pleasurefeeds, pureed with nectar thickened liquids. Provides: 1000 kcal, 44.3 gprotein, 1575 mL
total fluid with feed and flushes includingmed flushes
Food or Nutrient Delivery:
G-tube, PO pleasurefeeds
Nutrition education:
n/aat this time
Nutrition Counseling:
n/aat this time
Coordination of Care(refer to):
Nursingstaff
Goal(s): ProvideTF to meet needs without s/sx of aspiration
2013 SGSDI
TF rate/tolerance
PO pleasure feeds as tolerated, pureed consistency
Stable weight status
Regular bowel movements
MONITORING& EVALUATION
Indicators: Criteria:
TF rate/tolerance TF rate at 100 mL/hr x 10 hours, BMP and electrolytes WNL, residuals
Weight status <500 mL residuals
Bowel movements Stable weight
1-2 bowel movements every 3 days
Intern's Signature Date Preceptor's Signature Date
2013 SGSDl