Sage Dietetic Internship Inpatient NCP Form

Name: Ashley Prendergast

Patient ID: R.M.
Admit Date:
09/11/2015

Reason for Nutrition Consult: Diabetes Education

Admit Medical Diagnosis: cellulitis of the scrotum

Current Date:
09/21/2015

NUTRITION ASSESSMENT
Food and Nutrition Related History:
Not a big breakfast eater, sandwich and canned fruit for lunch, usually chicken or pork, an avocado, and salad for
dinner. Loves oat bread. Sometimes dessert. Drinks water, orange soda, iced tea throughout the day, occasionally
milk.
Good appetite, 100% of meal intake since admission. Longtime girlfriend at bedside referred to him as a bottomless
pit
Pts girlfriend reported being diagnosed with DM type II one month ago, received diabetes education at time of dx, has
been following CHO counting diet strictly and lost 7 lbs. Pt does not participate in girlfriends diabetic diet but
verbalized excitement in looking in the diabetic cookbook he bought for her to chose recipes for them to make.
No food allergies or intolerances
Current Inpatient Diet
Feeding Ability
Oral Problems
Order:
Independent
Chewing Problem
Limited Assistance
Swallowing Problem
CHO Counting
Extensive/Total Assistance
Mouth Pain
None of the Above
N/A
Explain:

Explain:

Physical Assessment:
Well-kept adult male, A x Ox3, obese, missing some dentation without interfering with chewing.
Anthropometric Measurements
Age:
Gender
Ht:
Current Wt: 104 kg
BMI:
57
M
180 cm
Admit Wt: 104 kg
32.11
IBW: 78.2 kg
Wt Hx (specify time frame):
BMI Classification:
104 kg
Obese Class I
% Wt change: none in as long
as pt can recall
Biomedical Data (list only pertinent nutrition-related labs)
Labs

Date
Hct
Hgb
WBC
Glu
38.1
12.6
14.9
115
Inpatient Medical Course Relevant to Nutrition (i.e. surgeries, procedures, tests, I/O, etc.):
Scrotal abscess debridement
PMH:
New dx of diabetes.
Hx: COPD, HTN, asthma
Pertinent Medications & Dosage
Heparin, insulin, lactated ringers, morphine and Percocet, antibiotics
Skin status:
X Intact Pressure Ulcer/Non-healing wound; Braden Score (only when skin is intact): 19
Comments: except surgical wound on scrotum

Estimated Nutritional Needs based on 84.6 kg for energy and 104 kg for fluid and protein
Calories (kcal/kg & total kcal/day)
Protein (g/kg & total g/day)
Fluid (ml/kg & total ml/day)
25-30 kcal/kg & 2115-2538 kcal/day
1-1.2 g/kg & 104-124.8 g/day
25-30 ml/kg & 2600-3120 ml/day

NUTRITION DIAGNOSIS (include IDNT codes)

P (problem) Food and Nutrition
related knowledge deficit related to:
P

2015-2016

E (Etiology) no previous diabetes

education
as evidenced by:
E

S (Signs & Symptoms) new diagnosis

of DM type II
S (Signs & Symptoms)

(problem)___________________________
____________________________related to:

(Etiology)____________________________
________________________as evidenced
by:

RATIONALE (required section):

1. Discuss reasons for including each abnormal lab:
Hematocrit and hemoglobin are low, possibly indicating over-hydration or
anemia. (1) White blood cells are high indicating infection (cellulitis of the scrotum).
Glucose was high on admission originally thought to be due to presence of
infection. Further review led doctors to suspect type II DM and request a nutrition
consult.

2. Discuss justification for choosing method of calculating needs (specify

equations & references used):
In the hospital, it is customary to use 25-30 kcal/kg as an estimate of energy
needs. When a patient is obese (this patient presents with a BMI of 32.11 kg/m2) we
use adjusted body weight for energy. This comes to 2115-2538 kcal per day. Protein
is calculated at 1-1.2 g/kg actual body weight for wound healing on scrotum. Fluid
recommendations were based on actual body weight at 25-30 ml/kg body weight.
This came out to be 2600-3120 ml/day.

References:
1. Pronsky Z, Elbe D, Ayoob K. Food Medication Interaction. 18th ed. Birchrunville, PA: FoodMedication Interactions; 2015.

2015-2016