NCP Report 3

Patient 3
Adolescent
I.

Introduction: Patient Profile

Patient 3 is a 17 year-old Hispanic female. She is originally from Honduras. She
was initially diagnosed with a mental illness in 2013. Pt is diagnosed with severe
major depression with psychotic features, PTSD, and borderline personality disorder.
Pt current nutrition-related problem is obesity.

II.

Disease Process
Obesity for children and adolescents has increased throughout the years.
Childhood and adolescent obesity can lead to social discrimination, low self-esteem,
and delayed academic and social functioning. Obese and overweight children are at
risk for developing cardiovascular disease, hypertension, hyperlipidemia, type 2
diabetes, asthma, hepatic steatosis, and sleep apnea.
Treatment for childhood and adolescent obesity is imperative to decrease risk for
future health consequences. There needs to be a sufficient family support system in
order to be successful in weight loss. Dietary recommendations for treatment of
pediatric obesity includes: reduction in caloric-dense, nutrient-poor foods, sugarsweetened beverages, sports drinks, and fruit juices. Increasing physical activity is
another treatment for pediatric obesity. At least 60 minutes of moderate-to-vigorous
physical activity a day is recommended for children and adolescents.

III.

Patient History
Pt 3 is diagnosed with severe major depression with psychotic features,
PTSD, and borderline personality disorder. Pt has history of self-harm behaviors;
her self-harm behaviors are cutting. Pt was placed in DFCS custody about one
year ago.

IV.

Course of Hospital Treatment

N/A
Nutrition Care
a. Assessment
Weight: 208 lbs= 94.54 kg
Height: 56= 66
BMI: ((208)/((66)(66)) x 703= 33.6 kg/m2
Growth Chart: > 95th percentile
IBW: 100+(5x6)= 130 lbs
%IBW: 208/130= 160%
AdBW: N/A

V.

Lab Values
N/A
Drugs

Drug
Augmentin 500
Benadryl
Geodon
Motrin
Zoloft
Zyprexa

Reason
Acute Sinusitis
Pruritus
Mood Stabilization
Toothache Pain
Depression
Severe Agitation

Interaction with Food

Take with food

Increases appetite

Nutrient Needs
Total kcals: 94.54 kg x 25 kcals= 2363.5 kcals
Protein: 94.54 kg x 1g PRO= 94g PRO
Fluid: 94.54 kg x 25 cc= 2363.5 cc
b. Diagnosis (PES) Statement
Excessive energy intake related to obesity as evidenced by above 95th
percentile on the growth chart, per HST report.
Obesity related to physical inactivity as evidenced by above 95th
percentile, visual assessment, medical records.
Food- and nutrition-related knowledge deficit related to mental status as
evidenced by dx of depression, borderline personality disorder, and PTSD.
Self-monitoring deficit related to mental status as evidenced by dx of
depression, borderline personality disorder, and PTSD.
c. Intervention Plan & Implementation
Pt 3 will reduce intake of fast foods and sugar sweetened beverages
including sports drinks, fruit juices, and carbonated drinks to 1 drink per day. Pt 3
will increase consumption of fruits and vegetables to 5-7 servings a day. Pt 3 will
increase physical activity to 30 minutes per day with progression towards 60
minutes per day in 30 days.
d. Monitoring/Evaluation
Will request lab values, will continue to monitor weights, record energy intake,
record physical activity.
e. Documented
Completed.