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Referred for:

Nutrition Related History: Pt visited this AM and was poor historian; AMS. Pt could not recall breakfast, but stated that appetite has decreased. Ptlivesinnursinghomewheremealsareprovided. Ptusuallyeatshot/coldcereal,juiceforbreakfast,tunasaladandicedteafor lunch, and orders take out from various restaurants for dlnner. Pt admits to drinking 4-5 cans of iced tea/day. Pt does not check blood sugars and does not follow anv soecial diets for DM. Pt reoorted normal wt is 180#. Anthrooometric Measurements BMI: 35.15 (Obese) Wt: 180# Age: 83 Gender: Female Ht: 60" Wt Hx: n/a % Wt change: n/a Biomedical Data, Medical Tests & Procedures other Hct Na+ I K+ Heb BUN Labs/Date I Albumin I Glucose HbAIC Creat Fe 29.1, n/a n/a \47 nla 4 n/a 34t s.1f 02/tt/t4 1r.94'l Medical Diagnosis: R Femoral neck fracture PMH/Relevant Conditions: HTN, DM 2, CAD, chronic anemia Fam Hx: n/a PertinentMedications: Januvia25mg/day,HumalogKwikPenL00unitspermL; 3mLsubcutaneous,Pradin2mg3x/dayVitaminBl 100mg/day, Vitamin B12 500mg/day
Food and

| 2.6J

Mcv I

Skin

status: X Intact n Pressure Ulcer/Non-healing wound; Commentsl Phvsical Assessment: posterior scalp abrasion , pain w/ R leg movement Estimated Nutritional Needs Based on Comoarative Standards:
Calories: Mifflin St. Jeor x 1.3 activity factor 1561-1B61kca l/day

Protein: 0.8-1.09/day 66-82e/dav Oral Problems

Fluid: 30ml/kg/day

ZLldav
I

Diet Order:
1600kcal ADA diet

Feedlng Abillty

nta ke

X n n n

lndependent Limited Assistance Extensive/Total Assistance

N/A

tr n n

Chewing Problem Swallowing Problem

Mouth Pain

X None of the Above

tr X tr I tr

Good (>75%) rair (approx. 50%)

Poor (<50%)

Minimal -(<25%l
NPO

!
P

No Nutritional Diagnosis at this

time

Proceed

to Nutrition Diagnosis Below

(problem): Limited adherence to nutritionrelated recommendations (NB-1.6) related to:

P

(problem) related to:

(Etiology): food and nutrition-related knowledge deficit concerning DM diet recommendations as evidenced by: E (Etiology) as evidenced bv:
E

S (Signs

& Symptoms): pt dietary recall and

GLU 194mg/dL
S (Signs

& Symptoms)

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Nutrition Prescription: Modification of distribution, type, or amount of food and nutrients within meals or at specified time (ND-1.2): recommend
1600 ADA diet to provide 1561-1861kca1, 180e CHO, 66-82s pro, 2.01 fluid per day Nutrition education: content (E-1)/application (E-2): food/meal planning Food or Nutrient Delivery: meals and snacks (ND-L): 1600kcalADA diet (180e CHo) approaches, CHO counting, reading food labels, portion control

Nutrition Counseline: n/a Goal(s): Achieve glycemic controlw/ compliance to recommended diet
Indicatb rs: Labs j'l

Coordination of Care (refer to): n/a

Criteria: Preprandial glucose 70-130mg/dL, ALc <7.0%

llt, r&
ln

l/

2l

t Date

/r

2/

tr
Date

Precepffi's Slgnature

2013

SGS DI