Download Answer Guide for Medical Nutrition Therapy: A Case Study

HTN
Sage NCP Form
Student Name: Michaela M. Phillips
Case: Middle Aged Man with Hypertension
Patient: 60 YEAR OLD MAN
Referred for: HYPERTENSION
NUTRITION ASSESSMENT
Food and Nutrition Related History:
No diet plan
Anthropometric Measurements
Age: 60
Gender: M
Ht: 5’9”
BMI: 34.7 kg/m2 (Obese)
Wt: 234 lbs
Wt Hx: NA
Biomedical Data, Medical Tests & Procedures
Labs/Date
Albumin Glucose HbA1C
BUN
Creat
110
mg/dL
Medical Diagnosis/Relevant Conditions:
Stage 1 Hypertension - 145/92 mm Hg
Na+
K+
136
mEq/L
Triglycer
ides
HDL
LDL
133
mg/dL
37
mg/dL
174
mg/dL
Total
Cholester
ol
238
mg/dL
Pertinent Medications/Supplements/Herbs:
Hydrochlorothiazide
Skin status:
x Intact □ Pressure Ulcer/Non-healing wound; Comments:
Patient/Client/Family Medical/Health/CAM History:
Estimated Nutritional Needs Based on Comparative Standards:
Calories 2448 (30 cal per kg Adjusted body
Protein 85g (.8g/kg BW - .8 x 234/2.2)
weight) = 30 x (179.5 lbs. / 2.2)
Current Diet Order None
Feeding Ability
Oral Problems
X Independent
□ Chewing Problem
□
□
Limited Assistance
Extensive/Total Assistance
□
□
X
Fluid 2.5 L (1 mL per kcal rounded to the
nearest ½ liter)
Intake
□ Good (> 75%)
□
X
□
Swallowing Problem
Mouth Pain
None of the Above
□ No Nutritional Diagnosis at this time
NUTRITION DIAGNOSIS
X
P (problem) NI-5.11.1 – Excessive mineral
intake
related to:
P (problem) NI-5.6.3 – Inappropriate intake of
saturated fat
related to:
E (Etiology) Overconsumption of salt
as evidenced by:
E (Etiology) Food and nutrition related
knowledge deficit concerning type of dietary
fat
as evidenced by:
Fair (approx. 50%)
Poor (<50%)
Minimal – (<25%)
Proceed to Nutrition Diagnosis Below
S (Signs & Symptoms) diet history; high blood
pressure 145/92 mm Hg.
S (Signs & Symptoms) diet history; Elevated
LDL (174 mg/dL)
INTERVENTION
Recommended Nutrition Prescription: Transition to hypocaloric DASH diet with nutrition education and counseling to prevent progression of
hypertension to stage II.
Food or Nutrient Delivery: Self
Nutrition education: Weight loss and blood pressure regulation; DASH
diet recipes and list of foods for the DASH diet. Benefits of physical
activity.
Nutrition Counseling: Cognitive behavior change; move to compliance
Coordination of Care (refer to): Social Work Services for Stress
with DASH diet. Physical activity frequency; motivate to increase to 5
management
times/week
Goal(s): Follow the DASH diet by reducing salt to 1500mg, increasing fruit/veg consumption to 9-10 servings, and nonfat dairy to 3
times per day in order to bring blood pressure under 120/80 mm Hg; reduce saturated fat to <10%,
Consume 2400 cal/day diet for weight loss of 1 lb / week. Long term goal is to lose 50 lbs in a year and maintain the DASH diet.
MONITORING & EVALUATION
Indicators: Blood Pressure
Food diary
Weight Loss
Criteria: under 120/80 mm Hg
DASH diet standards followed
1lb per week
© 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license
distributed with a certain product or service or otherwise on a password-protected website for classroom use.
NUTR 504 – HTN Case Study
Michaela M. Phillips
Title: Hypertension in a Middle-aged Man
1.
Define hypertension. Suggest how his high blood pressure would be classified and discuss how his hypertension affects
risk for future health problems.
Hypertension is defined as a persistent high arterial blood pressure. Systolic blood pressure (SBP), contraction
phase of the cardiac cycle, is 120 mm Hg or higher and diastolic blood pressure (DBP), relaxation of the cardiac
cycle, is 80 mm Hg or higher (Kraus, p758). There are three stages: prehypertension, stage I and stage II.
Prehypertension: 120-139 (SBP) / 80-89 (DBP) mm Hg
Hypertension, stage I: 140-159 (SBP) / 90-99 (DBP) mm Hg
Hypertension, stage II: ≥160 (SBP) / ≥100 (DBP) mm Hg
Hypertension can lead to many diseases including heart failure, end-stage renal disease, and peripheral vascular
disease.
2.
What is his IBW, %IBW, and BMI? Estimate his caloric requirements. Show your work.
IBW = 106 + (9 X 6lbs per inch over 5ft) = 161 lbs
%IBW = 234/161 x 100 = 143%
BMI = (234/2.2)/ (69inches x 2.54/100) 2 = 34.63 kg/m2
Adjusted body weight (AdBW) equation: AdBW = 0.25 (ABW-IBW) + IBW = .25(234-161) + 161 = 179.5 lbs
(Where: ABW = actual body weight; IBW =ideal body weight)
3.
Explain the DASH diet. What levels of saturated fat, cholesterol, fiber, sodium, potassium, calcium, and magnesium are
included? What would be an expected change in his blood pressure and blood lipids if he follows the DASH diet?
The DASH diet is a dietary pattern that has been shown to lower SBP by 8-14 mm Hg. It is low fat and includes lean
meat, nuts, fruits, vegetables and nonfat dairy products. It is high in potassium, phosphorus, and protein (not
advisable for end stage renal disease). A hypocaloric DASH diet has been shown to reduce blood pressure further,
improve vascular function and reduce left ventricular mass as well as promote weight loss.
Daily Nutrient Goals Used in the DASH Studies (for a 2,000-Calorie Eating Plan)
Total fat
27% of calories
6% of calories
Saturated fat
Protein
18% of calories
Carbohydrate
55% of calories
Cholesterol
Sodium
150 mg
2,300 mg*
Potassium
4,700 mg
Calcium
1,250 mg
Magnesium
Fiber
http://www.nhlbi.nih.gov/health/health-topics/topics/dash/
500 mg
30 g
© 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license
distributed with a certain product or service or otherwise on a password-protected website for classroom use.
HTN
4.
Analyze his diet using the MyPyramid Tracker. How many kcals is he currently consuming, and how does this compare
to his energy needs? He consumed a total of 2305 calories which is less than his energy needs. How does his usual diet
compare to the DASH recommendations? The DASH diet recommends consumption of fruits and vegetables, low-fat
dairy, and nuts; it recommends limiting sodium, total fat, saturated fat as well as appropriate calories for weight
management. While his diet did not exceed the energy requirements, it was high in saturated fat and extremely high in
sodium. Additionally, his consumption of fruits and vegetables and low fat dairy as recommended by the DASH diet
was virtually non-existent.
5.
What type of medication is he on for his blood pressure? Hydrochlorothiazide. Does it have any food-drug interactions?
This drug can cause hypernatremia and/or hypercalcemia, hypokalemia and/or hypomagnesemia (replaced by K/Mg
supplement).
6.
Go to http://www.kidney.org/professionals/kdoqi/gfr_calculator.cfm and enter his age, race, gender, and creatinine level
(check yes for “traceable to IDMS”). This calculates an estimated glomerular filtration rate (GFR), which is a measure
of kidney function. What is his estimated GFR (MDRD GFR in mL/min/1.73 m2)? 65 mL/min/1.73 m2. If these
readings persisted for at least three months, what would it suggest about the effects of hypertension on his kidneys? If
readings persist for 3 months or more, it would suggest chronic kidney disease.
© 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license
distributed with a certain product or service or otherwise on a password-protected website for classroom use.
NUTR 504 – HTN Case Study
Michaela M. Phillips
7.
Identify an appropriate nutrition diagnosis and write a PES statement.
NI-5.11.1 – Excessive mineral intake (P) related to overconsumption of salt (E) as evidenced by diet history and high
blood pressure of 140/99 mm Hg.
NI-5.6.3 – Inappropriate intake of saturated fat (P) related to food and nutrition related knowledge deficit concerning
type of dietary fat (E) as evidenced by diet history and elevated LDL of 174 mg/dL.
8.
Suggest specific modifications of diet and lifestyle (interventions) that might lower this client’s blood pressure.
Transition to the DASH diet, hypo caloric for weight loss, would lower his blood pressure.
9. What are your overall goals for this client, and how would you monitor the results or outcomes of your interventions?
Goals:
Follow the DASH diet by reducing salt to 1500mg, increasing fruit/veg consumption to 9-10 servings, and nonfat
dairy to 3 times per day in order to bring blood pressure under 120/80 mm Hg
Consume 2400 cal/day diet for weight loss of 1 lb / week. Long term goal is to lose 50 lbs. in a year and maintain
the DASH diet.
10. Write a note in ADIME or SOAP format that summarizes your assessment. See front page.
Assessment: 60yr old man with type A personality presents with high blood pressure 145/92 mm Hg.
Ht: 5’9”; Wt: 234 lbs; IBW: 161 lbs; %IBW: 143; AdBW: 179.5 lbs
Diet history reveals excess salt and saturated fat intake.
Estimated energy needs 2448 calories, 85g from protein. No diet order.
Client has elevated LDL (174 mg/dL), total cholesterol (238 mg/dL) and triglycerides (133 mg/dL) and low
HDL (37 mg/dL).
Diagnosis:
NI-5.11.1 – Excessive mineral intake (P) related to overconsumption of salt (E) as evidenced by diet history and
high blood pressure of 140/99 mm Hg.
NI-5.6.3 – Inappropriate intake of saturated fat (P) related to food and nutrition related knowledge deficit
concerning type of dietary fat (E) as evidenced by diet history and elevated LDL of 174 mg/dL.
Intervention:
Follow the DASH diet by reducing salt to 1500mg, increasing fruit/veg consumption to 9-10 servings, and
nonfat dairy to 3 times per day in order to bring blood pressure under 120/80 mm Hg
Consume 2400 cal/day diet for weight loss of 1 lb / week. Long term goal is to lose 50 lbs. in a year and
maintain the DASH diet.
Nutrition Counseling: Cognitive behavior change; move to compliance with DASH diet. Physical activity
frequency; motivate to increase to 5 times/week
Nutrition Education: Weight loss and blood pressure regulation; DASH diet recipes and list of foods for the
DASH diet. Benefits of physical activity.
.Monitoring and Evaluation:
Indicators
Criteria
Blood Pressure
Under 120/80 mm Hg
Food Diary
DASH diet standards followed
Weight Loss
1 lb per week
© 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license
distributed with a certain product or service or otherwise on a password-protected website for classroom use.