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    NCP Assessment Form

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    api-466194120
    #1 The patient is a 68 inch tall male weighing 235 pounds with a BMI of 35.7, classifying him as obese. He has gained 35 pounds over the past couple years. #2 His nutrition diagnoses include excessive energy intake due to lack of competing values from his busy job, eating out 4-5 times per week, and increased stress from his busy job. #3 The nutrition intervention plan is to prescribe a calorie-restricted diet of 2000-2100 calories per day and provide nutrition education on meal preparation and healthy options for eating out. The patient's goals are to limit eating out to two lunches and one dinner per week and lose 3 pounds in the next month.

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    NCP Assessment Form

    Uploaded by

    api-466194120
    286 views3 pages
    #1 The patient is a 68 inch tall male weighing 235 pounds with a BMI of 35.7, classifying him as obese. He has gained 35 pounds over the past couple years. #2 His nutrition diagnoses include excessive energy intake due to lack of competing values from his busy job, eating out 4-5 times per week, and increased stress from his busy job. #3 The nutrition intervention plan is to prescribe a calorie-restricted diet of 2000-2100 calories per day and provide nutrition education on meal preparation and healthy options for eating out. The patient's goals are to limit eating out to two lunches and one dinner per week and lose 3 pounds in the next month.

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    #1 The patient is a 68 inch tall male weighing 235 pounds with a BMI of 35.7, classifying him as obese. He has gained 35 pounds over the past couple years. #2 His nutrition diagnoses include excessive energy intake due to lack of competing values from his busy job, eating out 4-5 times per week, and increased stress from his busy job. #3 The nutrition intervention plan is to prescribe a calorie-restricted diet of 2000-2100 calories per day and provide nutrition education on meal preparation and healthy options for eating out. The patient's goals are to limit eating out to two lunches and one dinner per week and lose 3 pounds in the next month.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    286 views3 pages

    NCP Assessment Form

    Uploaded by

    api-466194120
    #1 The patient is a 68 inch tall male weighing 235 pounds with a BMI of 35.7, classifying him as obese. He has gained 35 pounds over the past couple years. #2 His nutrition diagnoses include excessive energy intake due to lack of competing values from his busy job, eating out 4-5 times per week, and increased stress from his busy job. #3 The nutrition intervention plan is to prescribe a calorie-restricted diet of 2000-2100 calories per day and provide nutrition education on meal preparation and healthy options for eating out. The patient's goals are to limit eating out to two lunches and one dinner per week and lose 3 pounds in the next month.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    The patient is obese, has a BMI of 35.7, has gained 17.5% of their weight over the past 12 months, and has a family history of obesity and hypertension. Their current calorie intake and eating habits need to be modified.

    The patient's current medical diagnosis is obesity. They have no other pertinent medical history. Their height is 68 inches, current weight is 235 pounds and ideal body weight is 200 pounds.

    The patient has excessive calorie intake due to lack of competing priorities and eating out frequently. They are also obese which is exacerbating their weight gain and increasing stress levels. Their BMI is 35.7 which classifies them as obese class II.

    Nutrition Care Process (NCP) Assessment Form

    Current Medical Dx: Obesity


    PMHx: None

    Ht: 68” Wt: 235# UBW: 200# DBW 154# %DBW 152% BMI 35.7
    %Wt Loss/Gain 17.5% Over 12 Months Intentional Unintentional No Change
    Dietary Intake/Appetite ____100___% No Change Fluid Intake ____2760_____ml
    GI Nausea Vomiting Diarrhea Difficulty Heartburn Bloating None
    Symptoms Chewing /
    Swallowing
    Oral Condition Own teeth or dentures Few teeth or lost dentures Edentulous (no teeth)
    Assessment wt: 106.8 Estimated needs Kcal 1708- (16-20 kcal/kg) Protein 85.4 (.8 gm/kg)
    kg 2136
    Fluid 3738 (35 mL/kg)
    Pertinent Nutrition Labs (Include Date):
    Chol 205 mg/dL Increased, HDL 35 mg/dL Decreased (1/10/2019)

    Pertinent Nutrition Related Medications/Supplements:


    Men’s Multi Vitamin

    Current Diet/Order/Regimen Calorie restricted to 2000 kcals/ day

    Physical Appearance/Assessment Appears obese and lethargic

    Skin Assessment Intact, Good Turgor Fragile/Tears Stage 1 or 2 Pressure Stage 3 or 4 Pressure
    Easily Ulcer/Surgical Wound Ulcer
    Nutritional No Risk Low risk Moderate risk High Risk
    Risk
    Comments: No food allergies, busy schedule, not active due to busy work schedule, gradually gaining weight over the
    past couple of years, father has HTN and obesity, brother has obesity, eats out 4-5 times per week

    Nutrition Diagnosis (PES Statement)


    #1Excessive energy intake related to lack of competing values (busy job) as evidenced by 35# weight gain over the past couple
    of years, BMI 35.7, working 100 hours per week, poor dietary choices and analysis of 24 hour recall.

    #2 Obesity related to excessive energy intake as evidences by BMI 35.7 (obese class II), overconsumption of high-fat and/ or
    energy dense food or beverage (eating out 4-5 times a week).

    #3 Obesity related to increased psychological/ life stress as evidenced by large amounts of inactivity (busy job), estimated
    excessive energy intake, BMI 35.7 (obese class II).

    Nutrition Intervention
    Nutrition Prescription 2000-2100 kcals/ day
    Intervention # 1 Energy modified diet of 2000-2100 kcals/day

    #2 Nutrition education on meal preparation, healthy options while out

    #3

    Patient Goal(s) #1 Patient consumes two lunches and one dinner out per week

    #2 Patient consumes 2000-2100 kcal/day at least four times a week

    #3 Patient will loss 3 pounds in one month

    Nutrition Monitoring and Evaluation


    # 1Will monitor for dietary intake by 24 hour recalls and weight.

    #2

    #3

    RD Signature
    Lily Feldman

    Explanation of Risk:
    I checked off that this patient was at a moderate risk because of his 17.5% weight gain
    over the past 12 months, which puts him in the obese class II for his BMI. Being obese is a
    precursor to other health issues down the road; therefore, if we can begin to monitor this we can
    limit the negative health outcomes.

    Suggestions from ESHA:


    After conducting the ESHA report, there are many suggestions I could make. For starters,
    he consumed over 6000 kcals and his food choices were not ideal. My first suggestion would be
    to limit the calories consumed to about 2000 kcals. This can be done by only getting one Big Mac
    instead of two, then I would suggest gradually getting away from the burger side of the menu to
    the salads, then not going to fast food restaurants completely. His sodium levels were also
    through the roof and this could be done due to all of the fast foods he consumes. With his obese
    state and family history of hypertension, he should watch his sodium levels and stay below 2,300
    mg per day. To limit sodium, he can replace French fries with lightly salted chips, fresh fruit or a
    side salad.
    ESHA
    Report:

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