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Try This! Directions: Answer All The Necessary Information Needed in The Column Below. Use

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Nutrition Care Process (ADIME Process) Lesson 05

Try this!
Directions: Answer all the necessary information needed in the column below. Use
your own profile such as your health, medication used/taken, personal, and diet history.
Answer Key Sheet
Name: _ Christine Joy Molina ____________ Score:________
Course/Year: __BSN 2B__ ______________ Date:______

Type of History & Information: Remarks:


Significant Information
Health History:
a.Current health problem(s) Chronic Anemia Had been diagnosed with
Arthritis anemia at the age of 7 and
Seafood Allergies arthritis at age 19. Family has
history of seafood allergy.
b.Past health problems NONE NONE
c.Family health history Asthma Family has history of Asthma
Seafood Allergies and seafood allergy.
Grandparents have asthma.
d.Previous surgeries NONE No surgeries or any hospital
admissions.
Medication History:
a.Prescription Medications Ferrous Sulfate For Anemia
b.Over-the-counter Paracetamol For fevers, colds, and coughs.
medications
c.Herbal & Dietary NONE No herbal or dietary
supplements supplements.
Personal History:
a.Age 19 years old Born on December 22, 2000
b.Gender Female Born as a Female
c.Height 5’4” / 162cm Last measured November 9,
2020
d.Weight 48kg Last measured November 9,
2020
e.Cultural/ethnic identity Ilonggo Grandparents are Negros
Occidental Ilonggo descent
f.Occupation NONE (College Student) Studying at Western Mindanao
State University taking up
BSNursing
g.Role in family Youngest Sibling Have 1 older sister who is 21
years old.
h.Educational, Motivational, Education: Graduated Senior High School
& Economic state High School Graduate at Regional Science High
(currently in College) School-IX in the ear 2019.
Motivational Status:
Family-centered and Goal- Family serves as motivational
oriented support and so as personal
Economic Status: goals.
Middle Class Family is categorized as
middle-class.
Diet History:
a.Food intake Adequate Eats 3 times a day with snack
in between meals.
b.Eating habits and patterns Eats 3 meals/day Eating adequately.
Snacks in between meals
c.Lifestyle patterns Workout 3-5 times a week Has been working out for 2
Jumping ropes 2-3 times a months now (November 9,
week 2020)
Chose jumping ropes as
medium because it is beneficial
for the whole body and cardio.

2.What can you say or Discuss about your historical and nutrition assessment results.
(Reaction paper).
Being a 19-year old with arthritis and chronic anemia, with which I was diagnosed at age
7, I have to be more conscious of my health. I also have to take note of my current weight and
height since it produces a BMI that is categorized as underweight because this might pose a
trigger to my current health conditions. Also, knowing my family’s health history, which I may
be able to acquire, I have to take action on ways how to prevent them from having them. One
way to prevent the development of a disease and promote health is by eating the right amount
and kind of food, which is why I include eating green leafy vegetables in my meals and eating
liver to increase the iron level in my blood. Moreover, being physically active reduces my risk
of having asthma since my body is used to physical activities.

Think ahead!
Directions: Research on the process of the Nutrition Care using ADIME-ADA Model.
1.Draw in a clean and clear long bond paper the NCP ADIME-ADA Model.
Answer Key Sheet
Name: _ Christine Joy Molin_________________ Score:________
Course/Year: __BSN 2B_____________________ Date:_________

2.Discuss briefly the concept.


The ADIME-ADA Model serves as a guide for the process of the nutrition care process
(NCP). ADIME is divided into 4 steps - assessment, diagnosis, implementation, and monitoring
with evaluation. The first step in the NCP is Nutrition Assessment. This step lays the foundation
for the remainder of the NCP. In NCP, the term ‘‘assessment’’ is used to represent all of the
information that was gathered to proceed through the NCP. The information included focuses on
details from the patient or the patient’s record: food history, biochemical data, medications,
patient statements, opinions, anthropometric measurements, and laboratory data. And this
information is obtained through different sources such as the client himself, his family, and past
health records. The Nutrition Diagnostic Statement can be extracted after critically evaluating the
subjective data, objective data, data from the chart, and that retrieved from the patient’s personal
information. With this, the nutrition and health provider may know the cause of nutrition-related
problems and would be able to address the right interventions. The nutrition interventions are
intended to eliminate or diminish the Nutrition Diagnosis. Activities are constructed to enable
the patient to work towards objectives set for them by themselves and their nutrition
professionals. Follow-up monitoring, of the signs and symptoms, is used to determine the impact
of the nutrition intervention on the etiology/signs and symptoms of the problem. Its purpose is to
determine the amount of progress made and whether goals/expected outcomes are being met.
This allows the dietitian to evaluate and improve problems that would be needing more thorough
and specific interventions. Throughout the Nutrition Care Process, it is important to document all
necessary data and information for later reference.

See if you can do this!

Nutrition Care Process.


Direction: Interview at least 1 (One) Client either from your family, friends, love ones, etc.,
with specific illness or disease/s and fill up the Nutrition Assessment Forms for NPC.
1.Apply Nutrition Care Process following the checklist and Nutritional Assessment Forms
*See appendices for the Forms. If no input/data; indicate “NONE/N/A”.
2.Conclusion and Recommendation.
*You may use the previous or past data in terms of Laboratory results.
Answer Key Sheet
Name: Christine Joy Molina__________________ Score:________
Course/Year: BSN 2B_________________________ Date:_________

NUTRITIONAL ASSESSMENT FORM:


I. PATIENT INFORMATION:

Patient’s Name (Last, First, Middle): Salas, Leonila, Cumawas Date: October 22, 2020___

Age: 71 years old Sex: F ⎕ M ⎕ 


Status: Single_____

Address: _550 Sampaguita St. Villa, Sta. Maria, Zamboanga City, 7000__________

Religion: _Roman Catholic____________ Occupation: ___NONE________

Height: 153cm Actual Weight: 65kg_BMI:_27.76kgs/m2 Underweight⎕ Overweight⎕ Obese⎕ 


DBW: __50kg__

Food Preferences: _Green leafy vegetables, fruits, fish, sweets and rice ____

Attending Physician:_Amilbahar J. Karim,MD.,FPCP,FPCC,FPSVM Medical Diagnosis: Hypertension_

Diet Rx: TER: 1,420kcal; eat less pork and beef meat; no shellfish foods

I. PHYSICAL DATA:

Weight Change: None⎕ ≥ 10% of usual weight ⎕  ≤ 10% of usual weight ⎕


Food Intake/Appetite: Excellent ⎕  Good ⎕ Fair ⎕ Poor ⎕
Bowel Movement: Regular ⎕  Irregular ⎕
Gastro symptoms in the last 2 weeks: No change⎕  Nausea,Vomiting⎕ Anorexia,Severe Diarrhea ⎕
 Light ⎕ Moderate ⎕ Active ⎕
Physical activity prior to admission: Bedridden ⎕ Sedentary ⎕

II. PERTINENT LABORATORY DATA:

Albumin:____________ FBS:__________ Triglycerides:___________ SGPT-ALT:__________


SGOT-ALT:__________ Na:___________ Creatinine:_____________ BUN:_____________
Uric Acid:____________ K:___________ Ionized Ca:____________ Phosphorus:___________
Cholesterol:___________ Others:________________________________________________________
III. MEDICAL NUTRTION
CLINICAL NUTRITION SERVICE NDSC Form No. 9
NUTRITION SCREENING & ASSESSMENT FORM
Name:
TER: __1,450_Kcal CHO: _235Room
gm No:CHON:Age:______
_54 gm Sex:____
Fats: _32_gmFile No:___________
Diagnosis:
Other Restrictions: _Pork meat, shellfish foods, beef meat____________________________________________________

SCREENING CRITERIA FOR POTENTIAL NUTRITIONAL RISK (check appropriate box)


Food Intake Burns Chronic Pain
Weigth
IV. Loss
PLANS/RECOMMENDATIONS: Sepsis Old Age
Physical Signs of malnutrition Multi Trauma Depression
Eat more fiber-rich
Radiation theraphy foods, and less sweet, salty, and cholesterol-rich
Peritonitis foods.________________________________
Dentures
Regular Check-ups (visit doctor)_______________________________________________________________________________
Expected Hospital Stay > 2weeks Fistulae Frequent diarrhea/vomitting
Measure and keep log every day of blood pressure. __________________________________________________________
Malabsorption
Encourage Cancer Anorexia
mild exercise such as walking and gardening.____________________________________________________
On tube feeding
SUBJECTIVE DATA OBJECTIVE DATA

Food Intake: ____ No change Heigth: ______(cm) Weight: ______(kg)


____ Mostly Liquids Usual Weight: ______kg. BMI
BML:______
: _________
Assessed by: CHRISTINE JOY MOLINA A
____ Sub-Optimal Weight Change:___% over___ months/week
____ Starvation Name of Dietitian over%Signature
IBW: ______
____ Poor intake prior to Significant Labs:
admission Albumin_____ Total Lym Count ______
Functional Capacity: ______ In bed HCT______ HGB _______
Date: November 9, 2020
______ Ambulatory Others:_________________________________
______ Needs assistance ______________________________________
____________________________________
Chewing / Swallowing Difficulties: ________ Medications : ________________________
Constipation: ______ Diarrhea:________ ___________________________________
Food Allergies:_____________________ ___________________________________
Present Diet Px : __________________

SCORING OF NUTRITIONAL RISK RELATED RISK FACTORS


Screening criteria for potential nutritional risk Mechanical / Digostive
Digestive problem(1pt)
Problem (1)
one check or more ( 1-2 points) Depressed Albumin (1point )
<85%or > 130 % Ideal Body Weight (1 point) Significant Lab Result (1 point)
Unintentional Weigth Loss _____% over ____ Other:________________________
months or weeks ( 2 points ) Total Points : __________________
A nutrition risk factor with the following total score indicates:
Low risk 2-3 Moderate > 3 High risk

Nutritional Status: Normal Moderate Severe Malnutrition


Malnutrition
DIETITIAN'S RECOMMENDATION
ShiftLeonila
diet toC._____________________________
Salas 71 Monitor F Caloric Intake
Nutrition Education Total Caloric Reqt._____________________
Request for Laboratory Data Total Protein Reqt._____________________
Other:________________________________________________________
_______________________________________________________

Name of Dietitian / Signature Date :_____________
License Number :________________
 153 65
50 27.76 kgs/m2
30 6
130%

NONE Losartan 25mg/day, Atorvastatin 20


NONE NONE mg/day, Aspirin 80mg/day, Carvedilol, Amlodipine
NONE 10mg/day,
TER: 1,420kcal Betahistine DICHL

 NONE

less salty, sweet, and oily foods 


 1450 kcal

Christine Joy Molina 11/09/2020

DIETITIAN’S PROGRESS
NOTES

Name of patient: Leonila C. Salas

DATE/TIME P-problem E-Etiology S-Signs and Symptoms


November 9, 2020/ PROGRESS NOTES RECOMMENDATION
12:30PM
Problem Overweight  Manage diet
 Manage weight control
Etiology High carbohydrate and high sugar-  Reduce amount of
rich food intake and sedentary carbohydrate intake and high
lifestyle sugar-rich foods.
 Do mild exercises such as
walking and gardening.

Signs and Symptoms Anthropometric Measurements:  Control intake of high


Weight: 65 kg carbohydrate-containing
Height: 153cm foods and high sugar-rich
BMI: 27.76 foods.
% IBW:130%.  Keep track of weight, BMI,
and % IBW on a daily basis.

CHRISTINE JOY MOLINA A


Name of Dietitian / Signature / PRC License No.

SAMPLE MENU
(24 Hours Food Recall-Food Intake)
MEALS QUANTITY MENU ITEM
BREAKFAST 1 pc Banana Banana (Lakatan)
2 pcs. Slice Bread Toasted slice bread
1 cup Coffee (brewed) Coffee with Sugar
2 tsps. Sugar

AM SNACK 1 slice Cake Chocolate Cake


1 glass Juice Orange Juice

LUNCH 1 pc Fried Fish Fried Milk Fish


2 cups Rice Rice
4 tsps Soy sauce Soy sauce
1 glass Water Water

PM SNACK Sandwich Tuna Sandwich


2 pcs Slice bread
3 tsps Tuna
1 tsp Mayonnaise
1 glass Cola Coca Cola

DINNER Pork Soup Pork Sinigang


5 pcs Pork cubes
2 cups String beans,
Eggplant,
Potato,
1 cup Rice Rice
1 glass Water water

BEDTIME ¼ cup Chocolate candy M & M’s chocolate candy


SNACK

Note: Additional SALT for cooking per day is _2_ tsp ONLY

Prepared By: __Christine Joy Molina____ RND


License #: _______________________________
Source:Zamboanga City Medical center
Nutrition and Dietetics ServicesZamboanga City, 2016

Food Plan/Menu pattern:

Breakfast: A,M. Snacks Lunch: A,M. Snacks Dinner: Bedtime


(Optional)
Fruits Rice Soup Rice Soup Rice
Meat Meat Meat Meat Meat Meat
Vegetables Vegetables Vegetables Vegetables Vegetables Vegetables
Rice/Cereals Beverages Rice Beverages Rice Beverages
Beverages Fats Fruits Fats Fruits Fats
Fats Sugar Beverages Sugar Beverages Sugar
Sugars Fats Fats
Sugar Sugar

Note: This serve as a guide in writing Sample Menu.

PREPARED BY: ASST. PROF. NARHUDA H. UNGA

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