ADIME
ASSESSMENT
The patient eats 3 balanced meals with 2 snacks periodically throughout the day. They consume a high intake of water. Breakfast and snack 1 are sugar-heavy which can cause a series of headaches and feelings of fatigue mid-day.
Knowledge: The patient has high knowledge about macro and micronutrients. They prepare food at home.
Physical Activity: The patient engages in high physical activity daily.
Anthropometric Levels: age, gender, height, weight, UBW (Usual Body Weight), IBW (Ideal Body Weight), BMI (Body Mass Index, does not count for muscle).
Physical Findings: no discoloration in the skin or eyes.
Additional Notes: The patient is an 18-year-old female with a BMI of 19 and is considered underweight. From physical activity to and fully balanced meal where all food groups are represented, the BMI is not bothersome. However, the patient does consume foods high in sugar in the morning which can cause blood sugar to spike resulting in an onset of migraines and fatigue to occur mid-day. Adding more fats and protein is their goal as well as monitoring symptoms a couple of hours post-meal.
DIAGNOSIS
Which domain does this fall into? Is it Intake, Clinical, or Behavioral?
Problem: Excessive caloric intake as related to
Etiology: lack of knowledge of healthier choices and serving sizes as evidenced by
Signs/Symptoms: BMI, self-reported gain in <6 months; description of
Nutrition Diagnostic Terminology.pdfINTERVENTION
Make Sure These are Measurable!
Going forward, patients need to consume less sugar in breakfast and snack 1. Patient needs to increase fats and protein. Some examples can be avocados, eggs, nut butter, chia, flax, or hemp seeds.
MONITORING & EVALUATION
The patient needs to track breakfast and snack 1 but also symptoms relating to fatigue and migraines 2-3 hours post-meal. Check-in in 2-3 weeks on fatigue and migraine impact on the patient.
