Introduction
A nutritional assessment is a combination of interpretations of anthropometric, laboratory, clinical, and dietary examinations’ results. In this case, a nutritional assessment is performed to determine a patient’s nutritional status, which is affected by the use of nutritional items. The information revealed in the analysis of the patient’s current nutrition, or diet is necessary to identify deficiencies or excesses of certain nutrients in the body.
Dietary Intake Forms and Nutrient Analysis
In the dietary intake evaluation, the method of recording food, that is, information about all foods and beverages consumed during the last period (in this case, a week), was chosen. Although the subject does not follow any particular type of diet, the recording was done as instructed and averaged 1,900 calories, which is below the daily norm (Dao 404). Further details and details of the patient are indicated.
Nutrition Assessment Data
Anthropometrics
Jane Hendrickson is a 33-year-old female with a total body weight of 110 pounds at 5 feet 5 inches tall. Her BMI is 17.75, which signals she is underweight (Reber et al. 5). The waist circumference is 25.5 inches. Body composition is rather thin, and Jane does not remember any significant weight changes within the last year.
Food/Nutrition-related History
Jane does not have any medical diagnoses or specific diets; she understands the need for healthy nutrition due to her work in medical care and training but does not always have the ability to follow it. She has been working as a night shift support operator for fourteen months already. Jane only eats normally at weekends; on weekdays, she eats consistently but not always enough. Moreover, she occasionally has no appetite after the night shift or after sleep.
Her main meal consists of potatoes or pasta, chicken or beef, and occasionally fresh vegetables. From time to time, if she has the time and desire, Jane adds bread or dessert. She usually has these meals twice a day, and the portions are quite large. In terms of micronutrients, she gets a lot of iron and vitamins, especially vitamin A, from consuming red meat and chicken liver, which she consumes at least twice a week. Macronutrients are represented by an abundance of carbohydrates from pasta and bread, as well as by protein from meat.
Meals outside the home and the work process are rare and contain mostly the same foods that Jane prefers to cook at home. She occasionally eats fast food, primarily a slice of pork or chicken burger, or a sweet dessert, which partially helps replenish her fat intake. She does not drink alcohol at all, thus having a positive effect on her overall health. The main emphasis in her meals is lunch and dinner, with no breakfast at all (meal times have been shifted due to the work schedule, but the names have been retained accordingly).
Biochemical Data, Medical tests and procedures
Jane has not had a doctor’s appointment, examination, or medical tests in the past two years except for the COVID-19 vaccination. On the one hand, this indicates acceptable health and well-being. On the other hand, she is busy almost all the time at work and prefers to spend her free days with family or friends. For a complete analysis, she would have been advised to have a nutritional biochemical blood test (Reber et al. 9). A whole blood assessment, plasma, or serum analysis would be helpful. According to the information Jane provided, she is unaware that any of her immediate family members have a severe or genetically transmitted disease.
Nutrition-focused Physical Findings
The hair of the patient is moderately oily, with no hair loss problems. Overall, skin is dry, with a noticeable lack of subcutaneous fat; skin is thin under the eyes, and cheek bone is clearly palpable (Nutrition Focused Physical Exam). The collarbones are prominent, which also indicates a lack of subcutaneous layer – on the back and hips are also noticeable signs of insufficient mass. She does not complain about her well-being but notes periodic weakness, occasional apathy, and unwillingness to be active.
Assessment Summary
Brief Introduction of the Subject
33-year-old female, body weight 110 pounds, height 5 feet 5 inches. BMI is 17.75, waist circumference is 25.5 inches. Body composition is rather thin, no significant weight changes within the last year. Noticeable lack of subcutaneous fat; skin is thin under the eyes, collarbones and pelvic bones are prominent. General pallor is observed.
Justification of the Diet Intake and Analysis Method Used
In assessing dietary intake, the food registration method was chosen because the assessed did not provide health complaints and did not follow special diets. The period of one week was chosen as a food diary period (Dao 405). There are several obvious reasons why Jane’s diet is not wholesome. The lack of a meal after bedtime almost every day is compensated by a large cup of tea with milk or coffee with cream, which cannot provide the necessary amount of energy for the normal functioning of the body (Kane and Prelack 39). She claims that she has no desire to eat breakfast, but after a couple of hours, her body is hungry and lacks nutrients. Work shifts can occasionally last up to 12 hours, and lunch breaks are only half an hour. It is not conducive to healthy eating, despite a relatively healthy set of foods, especially since the portion sizes are substantial for someone of such a small weight and low body mass index.
Nutrition Care Plan Description
Several points are included in the recommendations for correcting dietary intake and composition. With their help, Jane can improve her well-being over time and fix the necessary micronutrient and macronutrient deficiencies.
Start and continue to eat breakfast on a regular basis. A few suitable options can be suggested for simplicity:
- Make sandwiches on the weekends for the convenience and speed of taking breakfast;
- Try accompanying breakfast with a glass of milk or natural juice instead of coffee;
- Prepare scrambled eggs or instant porridge, if possible, supplemented with vegetables or fruit before work.
Actively add fruit to the diet, at least 1-2 times a day. Since Jane’s diet includes almost no fruit, it is suggested:
- Purchase a few types of fruit that are easy to transport to work and keep them in the refrigerator (citrus fruits, apples, pears, banana);
- Purchase a larger fruit, divide it into portions and take one each day (pineapple, watermelon, melon);
- Try making a fruit salad or smoothie (this also combines with commodity number 1 and is suitable as a breakfast).
Diversify the diet by adding additional nutrients that are hardly found in Jane’s standard set:
- Seafood in any form, rice side dish recommended, once or twice a week;
- Add sweets, perhaps bitter chocolate, marmalade, or marshmallows, in small quantities to make up for possible glucose deficiencies.
Try additional cooking methods, such as steaming vegetables or cooking meat with sous vide.
In the case of prolonged shifts, introduce another small meal to prevent strong feeling of hunger between lunch and dinner – a small meat or fish sandwich or fruit, for example, a banana.
ADIME Chart Note
A: 33 y/o female.
Dx: underweight, malnutrition. Hx: loss of appetite, chronic sleep deprivation.
Current Diet Order: No diet.
Ht: 5’5″ (167.6 cm), Wt: 110# (49.8 kg), UBW: 111# (50.4 kg), BMI: 17.75 kg/m2, %UBW: 99.09% (<1% unintentional wt loss ´ 1 year), EER: 2000-2100 kcal (40-42 kcal/kg); 10-30% energy: 37 – 110 grams (146 – 439 kcal) (USDA); 0.83 g/kg body weight: 41 grams (166 kcal) (WHO), Meds: No meds.
Skin: Dry, clear.
Labs: No results currently.
D: Malnutrition related to inadequate oral intake as evidenced by usual dietary intake of approximately 1800-1900 kcal and 25-30 g of protein meeting approximately 85% of estimated energy and protein requirements; noted pallor and lack of subcutaneous fat layer, slightly increased risk of diabetes and cardiovascular disease.
I: Increase energy and protein intake through the dietary intake correction. Encourage additional regular meals, fruit and seafood consuming. Advise patient to take fluids between meals.
ME: Monitor daily weights. Monitor patient acceptance of diet, supplements. Monitor labs: lipid panel, BUN, Cr, serum electrolytes, CBC, glucose, B12, Vitamin D, Vitamin A, zinc, copper, selenium. Monitor patient’s adherence to intake regimen.
Works Cited
Dao, Maria Carlota, et al. “Dietary Assessment Toolkits: An Overview.” Public health nutrition, vol. 22. no. 3, 2019, pp. 404-418, Web.
Kane, Kelly, and Kathrina Prelack. Medical Nutrition Therapy. Jones & Bartlett Learning, 2019.
“Nutrition Focused Physical Exam.” Vimeo, uploaded by Iowa State University, 2016, Web.
Reber, Emilie, et al. “Nutritional Risk Screening and Assessment.” Journal of clinical medicine, vol. 8, no. 1065, 2019, Web.