Anemia in pregnancy

t Sample Nutrition Assessment: Nutrition assessment for 52 YOM admitted with CHF exacerbation and hyperglycemia. He has a PMH significant for type 2 diabetes and hypertension.

Anthropometrics: Pt is 5' 9" with a current body weight of 215 pounds. His IBW is 160 pounds, and he is currently 1,34% of his lBW. Pt reportsthat his usual bodyweight is around 220 pounds (about l- month ago); he is at 98% of his usual body weight with a weight change of about 2%in a L month time period. His current BMI is 31-.7 which puts him in the obese class l category.

Nutrition-related medications: Pt is currentlytaking Metformin bid. He has been placed on sliding scale insulin during admit for glycemic control. Also noted that pt is on solu-medrol which may contribute to hyperglycemia.

Biochemical data: Glucose at admission was elevated at 315 mg/dl. Pt's most recent Hgb A1C was elevated at7.7%. BS Glucose x 24 hours: 98-207 mg/dl. Pt reports that at home, his glucose typically runs from around 90-150 mgldl.

Pt's estimated energy needs are 1800-2100 kcals/day (25-30 kcal/kg IBW). Protein needs are estimated to be 58-73 e/day (0.8-1 em/ke IBW). Noted that MD placed patient on a 1.5 L fluid restriction. His current diet order is: 1800 calorie carb controlled Diet.

Food/Nutrition-related history: Patient reports that he typically eats 2 meals per day and L snack at bedtime. He usually skips breakfast because he is too busy to eat in the mornings. He states that he usually eats lunch at a fast food restaurant and his wife usually cooks dinner.

24 hour diet recall: Lunch- cheeseburger and medium French fries from fast food restaurant, large Coke Dinner- Baked chicken breast (4 ounces), l cup macaroni and cheese (homemade), buttered peas (7/2 cup),24 ounces sweet tea Bedtime snack: slice of apple pie

Pt denies having any current Gl issues but does report intermittent constipation. Hetakes Colace at home when needed for constipation.

Pt reports that he is mostly sedentary and works an office job where he sits at his desk for 8 hours per day. He does take his dog on a walk in the evening most nights, walking at a slow pace for about 1.5 minutes. He reports that he would like to start exercising more in order to have more energy and to improve his health. Pt is interested in losing some weight and improving his blood glucose lab values.

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Writing out a Nutrition Assessment Note

lnclude all appropriate ond relevont dssessment inlormation. Remember ABCD inlormation.

L. Current Medical Diagnosis, PMH (Past medical history) 2. Anthropometrics (height, weight, l9w,% lBW, uBW, % uBW, % weight change, BMI) and

evaluation of these values 3. Medications, potentialfood and drug interactions 4. Lab values (are they WNL, Low, or elevated?) lnclude units on the values 5. Estimated nutrition needs: Calories, protein, fluid 5. Dietary information (24 hour recall, diet recall information, nutrition history, etc) 7. Any Gl problems? Nausea, vomiting, diarrhea, constipation 8. Physical activity information

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