Download Sage Dietetic Internship - NCP Form

Sage NCP Form
Student Name: Kaitlyn Witz
Case: Hypertension
Patient: John Ry
Referred for: high blood pressure
NUTRITION ASSESSMENT
Food and Nutrition Related History: high blood pressure, limited physical activity due to pain in feet and legs. Diet high in added salt.
Anthropometric Measurements
Age:60
Gender: male
Ht: 175.3 cm
Biomedical Data, Medical Tests & Procedures
Labs/Date Albumin
Glucose HbA1C
11/13
4.2 g/dL
110
mg/dL
BUN
21 mg/dL
Wt: 106 kg
Wt Hx: not specified
Creat
1.2
mg/dL
Na+
135
mEq/L
BMI: 34.6
K+
4.6
mEq/L
Hgb
Hct
MCV
Other
LDL-174
mg/dL!
(high)
Cholesterol238
mg/dL!(high)
Medical Diagnosis/Relevant Conditions: Hypertension
Pertinent Medications/Supplements/Herbs: Hydrochlorothiazide
Skin status:
□ Intact □ Pressure Ulcer/Non-healing wound; Comments:
Patient/Client/Family Medical/Health/CAM History: none specified
Estimated Nutritional Needs Based on Comparative Standards:
Calories:2900 kcal according to EER
Protein: 84 g
Current Diet Order
Feeding Ability
□ Independent
□ Limited Assistance
□ Extensive/Total Assistance
□ No Nutritional Diagnosis at this time
NUTRITION DIAGNOSIS
□
Oral Problems
□ Chewing Problem
□ Swallowing Problem
□ Mouth Pain
□ None of the Above
Proceed to Nutrition Diagnosis Below
P (problem) NB 1.1 Food and nutrition related
knowledge deficit
E (Etiology) poor diet
P (problem) NB 1.7 Undesirable food choices
E (Etiology) poor diet
Fluid: 2.9 L
Intake
□ Good (> 75%)
□ Fair (approx. 50%)
□ Poor (<50%)
□ Minimal – (<25%)
S (Signs & Symptoms) BMI 34.6, high blood
pressure 145/92, high total cholesterol
238 mg/dL, high LDL cholesterol
174mg/dL, low HDL cholesterol 37 mg/dL.
S (Signs & Symptoms) BMI 34.6, high blood
pressure 145/92, high total cholesterol
238 mg/dL, high LDL cholesterol
174mg/dL, low HDL cholesterol 37 mg/dL.
INTERVENTION
Recommended Nutrition Prescription: Adopt DASH diet to reduce blood pressure to normal range of 120/80, with saturated fat
accounting for only 6% or less total kcals. The DASH diet will also keep sodium levels at 1500-2300 mg per day. Recommended
intervention also includes increasing physical activity to 45-60 minutes per day/ 5 days a week. I would recommend the patient loses
1 lb per week by consuming 250 kcals less per day and burning an excess of 250 kcals per day.
Food or Nutrient Delivery: ND-1- include a variety of foods consisting of
grains and/or starches, meat and/ or meat alternatives, fruits and
vegetables, and milk or milk products
Nutrition education: E-1- : E-1-instuction or training intended to lead to
nutrition- related knowledge. Refer to physician
Nutrition Counseling: C-1 to lower blood pressure to 120/80
Coordination of Care (refer to): physician
Goal(s):follow the DASH diet by keeping sodium levels at 1500-2300 mg per day, consume only 6% or total kcals from saturated fat,
and increase fiber to 25 grams per day. Other goals include increasing physical activity to 45-60 minutes per day/ 5 times a week and
decreasing blood pressure to a level of 120/80.
MONITORING & EVALUATION
Indicators: BMI- 34.6, high blood pressure-145/92, high total
cholesterol-238 mg/dL, high LDL cholesterol-174mg/dL, low HDL
cholesterol-37 mg/dL.
Criteria: Monitor and evaluate diet through food diary to evaluate the
progress of patient following DASH diet. Track level of physical activity
by having patient keep an exercise diary. Also, check BMI regularly by
checking weight status. Evaluation will be monitored by regular blood
pressure tests, as well as testing total cholesterol.
Kaitlyn Witz
Case Study CVD
1) Hypertension is defined as persistently high arterial blood pressure, the force exerted per unit area on the
walls of arteries. To be defined as hypertension, the systolic blood pressure (SBP), the blood pressure during
the contraction phase of the cardiac cycle, has to be 120 mm Hg or higher; of the diastolic blood pressure
(DBP), the pressure during the relaxation phase of the cardiac cycle, has to be 80 mm Hg or higher; this is
reported as more than 120/80 mm Hg. The patient’s blood pressure was 145/92 which classifies him as having
Stage 1 hypertension. The patient’s hypertension increases his risk of cardiovascular disease (CVD), as well as a
increased risk of fatal stroke, kidney disease, and organ damage.
2) According to Krause, the patients IBW is 151 lbs. (106 lbs. per 5 feet + 5 lbs each for the additional 9 inches).
The patients IBW is 64.5% ( IBW 151 lbs/ Actual Body Weight 234 lbs.). The patients BMI is 34.6 ( 106 kg/ 1.75
m2).
3) The DASH diet is shown to be effective in preventing and treating prehypertension and hypertension. The
diet study shows that this low-fat dietary pattern (including lean meats and nuts and emphasizing fruits,
vegetables, and nonfat dairy products) decreased SBP. Foods should be low in sodium but adequate for weight
management. According to the U.S Department of Health and Human Services, levels are as follows: saturated
fat-less than 6% of total kcals; cholesterol-150 g; fiber-30 g; sodium-1500-2300 mg; potassium-4700 mg;
calcium-1250 mg; and magnesium-500 mg. These changes should decrease his blood pressure and blood lipid
values.
4) The patient is currently consuming 2067 kcal according to the USDA’s food tracker. According to Krause, his
energy needs are 2900 calories to maintain his current weight. This puts him in a negative energy balance. This
may or may not reflect the patient’s typical daily intake. His diet does not compare with the DASH diet. Dash
recommends less than 6% of total kcals comes from saturated fat whereas his diet consumed 25%. DASH
recommends a daily intake of 150 mg of cholesterol, and his diet includes 912 mg. His diet only had 4 g of
fiber, whereas DASH recommends 30g. Importantly, DASH recommends a diet with 1500 to 2300 mg of
sodium, and his diet includes 7976 mg. DASH also recommends a diet with 4700 mg or potassium, and his diet
includes 2418 mg. DASH recommends 1250 mg of calcium and his diet has 1053 mg. DASH recommends 500
mg of magnesium and his diet included 191 mg. The patient’s diet is well above the AMDR for total fat. The
AMDR is between 25-35% of total kcals, and he was at 57%.
5) The patient is on hydrochlorothiazide for his high blood pressure. This drug increases urinary excretion of
potassium, magnesium, and sodium so it is recommended that his diet is high in potassium and magnesium. It
is advised to avoid natural licorice which may counteract the diuretic effect of the drug. Monitor electrolytes;
supplementation may be necessary. Use caution with calcium supplements.
6) According to the glomerular filtration rate (GFR) calculator, his estimated GFR is 62. A GFR of 60 indicates
chronic kidney disease, so if these readings persisted for at least 3 months it would suggest he would be
developing chronic kidney disease.
7) Two PES statements include:
NB 1.1 Food-and nutrition- related knowledge deficit
Related to: poor diet
As evidenced by : high- BMI 34.6, high blood pressure- 145/92, high total cholesterol- 238 mg/dL, high LDL
cholesterol-174mg/dL, low HDL cholesterol-37 mg/dL.
NB 1.7 Undesirable food choices
Related to: poor diet
As evidenced by: BMI- 34.6, high blood pressure-145/92, high total cholesterol-238 mg/dL, high LDL
cholesterol-174mg/dL, low HDL cholesterol-37 mg/dL.
8) I would suggest that the patient adopt the DASH diet by increasing fruit, vegetable, low-fat dairy, and nut
consumption, consuming foods low in sodium, saturated fat, and processed meats. He should also consume
foods high in fiber. 5-10 servings of fruits and vegetables would increase his fiber content. I would also
recommend that the patient eliminate the amount of added salt to his foods. Increasing the clients activity
level to 45-60 minutes 5 times a week would also help with his stress level and his blood pressure. The client
should follow a weight loss plan that will decrease his BMI to a number closer to 24.9 by decreasing kcal needs
by 500/day. This can be achieved by decreasing his kcal needs by 250, and burning an excess of 250 kcals per
day through exercise.
9) My overall goals for this client are to: follow the DASH diet by keeping sodium levels at 1500-2300 mg per
day, consume only 6% or total kcals from saturated fat, and increase fiber to 25 grams per day. Other goals
include increasing physical activity to 45-60 minutes per day/ 5 times a week and decreasing blood pressure to
a level of 120/80.
10) ADIME assessment:
Assessment: Patient is a 60 year old male with hypertension. Patient’s height is 175.3 cm and weight is 106 kg
with a BMI of 34.7. Patients blood pressure 145/92. Medications: hydrochlorothiazide; Patient has high total
cholesterol at 238 mg/dL, high LDL cholesterol at 174mg/dL, and low HDL cholesterol 37 mg/dL.
Diagnosis:
2. NB 1.1 Food and nutrition related knowledge deficit
related to: poor diet
as evidenced by: BMI 34.6, high blood pressure 145/92, high total cholesterol 238 mg/dL, high LDL cholesterol
174mg/dL, low HDL cholesterol 37 mg/dL.
NB 1.7 Undesirable food choices
related to: poor diet
as evidenced by: BMI 34.6, high blood pressure 145/92, high total cholesterol 238 mg/dL, high LDL cholesterol
174 mg/dL, low HDL cholesterol 37 mg/dL.
Intervention: Recommended intervention for this client is to adopt the DASH diet to reduce blood pressure to
normal range of 120/80, with saturated fat accounting for only 6% or less total kcals. The DASH diet will also
keep sodium levels at 1500-2300 mg per day. Recommended intervention also includes increasing physical
activity to 45-60 minutes per day/ 5 days a week. I would recommend the patient loses 1 lb per week by
consuming 250 kcals less per day and burning an excess of 250 kcals per day.
Monitoring and Evaluation: Monitor and evaluate diet through food diary to evaluate the progress of patient
following DASH diet. Track level of physical activity by having patient keep an exercise diary. Also, check BMI
regularly by checking weight status. Evaluation will be monitored by regular blood pressure tests, as well as
testing total cholesterol.