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- Should include relevant data only - Should include PES statement for nutrition diagnosis
- Patients may have more than one diagnosis, but try to choose the one or two most pertinent, or the ones you mean to address What do you recommend or plan to do to address the nutrition diagnoses?
Recommend change in food-nutrient delivery (supplement, change in diet, nutrition support, vitamin-mineral supplement) (NI)
Nutrition education (E)
Nutrition counseling (C)
Coordination of nutrition care (RC) What will you monitor to determine if the nutrition intervention was successful?
Generally based on the signs and symptoms
Clinical symptoms Assessment
A 34 y.o. male s/p MI with history of htn, DM2, hyperlipidemia; ht: 5 ft. 10 in; wt: 250 lb; BMI 36, obesity II. Patient works night shift, eats two meals a day, before and after his shift--fried foods, burgers, ice cream, beers in restaurants.. Does not add salt to foods. Activity: Plays golf 1x month.
Excessive energy intake (NI-1.5); excessive sodium intake (NI-5.10.2) related to frequent use of restaurant foods as evidenced by diet history.
Provided basic education (E-1) on 3-4 gram sodium diet and wt. management guidelines (nutrition education); pt to return to outpatient nutrition clinic for lifestyle intervention (C-2.1)
Monitoring & Evaluation
Evaluate weight (S-1.1.4), blood pressure (S-3.1.7), diet history at outpatient visit sodium intake (FI-6.2); energy intake (FI1.1.1); fat intake (FI-5.1.1) Re-check lipids in 3 months (S-2.6) A – Assessment
D – Diagnosis
I – Intervention
M – Monitoring
E - Evaluation