Question

CASE STUDY

Stephanie said “I hate being fat.” Client history: Stephanie is a 43-year-old mother of three who has experienced gradual weight gain after the birth of each of her children. She is 5 ft 7 in tall, weighs 189 pounds, works full time, and does not engage in regular exercise. She is considered prediabetic and has prehypertension and appears eager to make lifestyle changes to improve her health and be a better nutritional role model for her children. She has successfully lost weight in the past through intake of laxatives but eventually got bored and regained all of the weight she lost. She does not want to count calories. She wants to know how many servings from each food group she should eat to lose weight and what the best foods from each group are. Her usual intake is as follows: no breakfast; snacks at a vending machine twice a day; fast food for lunch; and dinner with the family. Her dinner usually consists of about 6 oz of meat, potatoes, sometimes a vegetable, bread with butter, and dessert. Stephanie admits to a weakness for “sweets.”

1. Identify and write the relevant and vital assessment data
2. Develop a Nutrition Diagnosis basing on the Nutrition Terminologies which is applicable to the patient
3. Formulate a patient’s Nutrition Goal
4. Identify appropriate Nutrition Goal
5. Utilize the ADIME Nutrition Documentation

Answer 1

1) Relevant and vital assessment data include :-

Objective data :-

- Age -43years

- Anthropometric measurement :

Weight - 189lbs

Height - 5 foot 7inches

Subjective data :-

- Is pre-diabetic and prehypertensive

- Do not do exercise

- Eats mostly from outside

- Not eat breakfast and has a weakness towards sweets.

2) Nutritional diagnosis - Imbalanced nutrition more than body requirments.

3) Patients Nutrition goal - To reduce the weight

4) Appropriate nutrional goal -

To identify inappropriate behaviors and consequences associated with overeating or weight gain.

To make a change in eating patterns and involvement in individual exercise program.

To loss weight with optimal maintenance of health.