Adime Note
Adime Note
Adime Note
Nutrition Assessment:
Client History:
20-year-old Caucasian male
English speaking
Full time student (Programing Technologies)
Full time employee (Assistant Manager at a technology retail store) (has one
day off each week)
Family history of CVD and high cholesterol
Lives in an apartment with college roommate
Not Married
Food & Nutrition History:
Sedentary Lifestyle
Was active in high school played tennis
Does not eat breakfast regularly
Eats convenience and fast foods due to busy lifestyle
Few snacks will occasionally have popcorn if watching a movie
Can cook convenience foods but usually does not cook full meals
Does not take a multivitamin
Allergic to bananas and grapes
Prefers canned fruits and vegetables over fresh
No diet history
Willingness to change 7 because he knows he needs to make the change
but is unsure of how or if he can
The patient has problems when he eats in front of the TV with over
consumption
Shops mainly by price
Anthropometrics:
59
210 # (IBW=160#)
BMI 31 Obese
Biochemical/Tests/Procedures:
No recent tests
Nutrition Focused Physical Findings:
Busy lifestyle between homework school and work
Comparative Standards:
Basal) Energy Expenditure= 5 + 10 (95.45) + 6.25 (175) 5(20)=1953
*1.3 (AF) * 1.0 (IF) = 2540 kcal per day
actual = 2153 (85%)(low)
The patient agreed that if he did not change his habits that he could further
his obesity and develop cholesterol problems like his father and would be
stuck taking medications and fearing a heart attack.
Education:
I taught the patient how to measure certain food items for the correct portion
size and how meal prep and packing his lunches would save him money and
be healthier in the long run. I showed him what MyPlate looks like and I
taught him how to read labels. We also discussed how he could get more
active after doctor approval.
Counseling Techniques:
We used goal setting because the individual was ready to change and
seemed like a success driven individual due to his responsibilities as a
manager and student
Referral of Care:
MD for activity approval
Goals:
Eat at the kitchen table instead of in front of the TV to avoid mindless eating
Meal prep for the week on Mondays when the patient does not have work
and little school to consume less convenience foods
Become more active by playing Tennis with his girlfriend at least twice a
week (log all activity)
Pack a lunch for work to avoid going out to eat
Lose 1 # per week with 2100 kcal diet and activity
Consume at least 3 servings of fruits and vegetables each day to start out
with.
Monitoring and Evaluation:
(Criteria/ Parameter)
Monitor food record for 2100 kcal per day
Monitor food record for correct portion sizes and 3 servings of fruits and
vegetables per day
Monitor activity log (tennis 2 times per week)
Monitor weight for weight loss of 1 # per week
Talk with patient about where he has been eating (should be at kitchen table)
and how the food preparation for the week has been going (prep on Mondays
and pack lunches for work)