Occurred: Recorded:

AbnormaL?

Date
L0

Time By /31,/t3 1.150 NPD Dooling,Nichole LO /31,/L3 l-222 NPD Dootring, NichoLe

Nurse DIET DfET

, CategorY Dietary Note

Confidential?

NUTRITION ASSESSMENT PROBLEM: LIMTTED ADHERENCE TO NUTRfTION-REI,ATED RECOMMENDATIONS RT DIFFICULTY MAKING DIET/LIFESTYLE CHANGES AEB PT REPORT OF DIFFICULTY FOLLOWING FOOD AND NUTRITTON-RELATED RECOMMENDATIONS AND PT REPORT OF SKIPPING LUNCH. PT NPO FOR RADIOLOGY. PT REPORTS GAINING 30# OVER THE SUMMER, TRYING TO LOSE WEIGHT AND TRYING TO STICK TO FOLLOW DM AND RENAL DIET BUT IS HAVING DIFFICULTY. PT CHECKS BLOOD SUGAR 10-12 TIMES A DAY AND IT RANGES FROM 30-400. PT DECLINED ED AS SHE SEES THE DIETITIAN AT DIA],YSIS CENTER A}TD HAS ED MATERIALS AT HOME. PT USUALLY EATS SPECIAL K SANDWICH FOR BREAKFAST, OFTEN SKIPS LI]NCH OR HAS GRANOLA BAR AND FRUIT, AND A HEAITHY CHOICE FROZEN MEA], FOR .; DINNER. PT DOES NOT LIKE TO COOK. LABS: FS 266, GLU 255, BUN 91-, CR 8.5, K 5.7, Al-C e OO/4/L3\ WT. 242 HT. 5'7" BMI 52 (CLASS III OBESE) EST NEEDS: 2093-2293KCAI' (-500 KCAL TO PROMOTE WEIGHT LOSS) 200G CHo

88-L10G PRO 2.7L

FLUID

GOAL: PT TO ADHERE TO RECOMMENDED DIET TO MAINTAIN GLYCEMIC CONTROL

INTERVENTION:

1. PT DECLINED DIET ED 2. ENCOI]RAGE PT NOT TO SKTP MEAIS 3. MONTTOR INTAKE, WEIGHT, LABS 4. FOIILOW HOSPITAL PLAN OF CARE