Examples for Nutrition Care Process Case study #1

Transcript:Examples for Nutrition Care Process Case study #1:
Examples for Nutrition Care Process Case study #1 34 y.o. male with history of Hypertension, DM2, hyperlipidemia; ht: 5 ft. 10 in; wt: 250 lb; BMI 36, obesity II. Patient works night shift, eats two meals a day, before and after his shift fried foods, burgers, ice cream in restaurants. Does not add salt to foods. Activity: Plays golf 1x month. Case study #1 cont’d Case study #1 cont’d Excessive energy intake (NI-1.5) R/T frequent use of restaurant foods AEB diet history, BMI 36, DM2, and hyperlipidemia. Case study #2 50 y/o white female, Dx of multiple allergies, including milk allergy. Her wt=114 lb, ht= 5'6". She has come to see you in the outpatient clinic of the hospital. No available lab work. She tends to fatigue easily & to have a lot of GI distress. Recently, she has had chronic mild diarrhea after meals. She has copies of 4 diets that she uses in sequence to try to cure her disease. From her intake records & patterns, you identify that she is consuming hidden milk products ( in cheese sauces, cream sauces, & salad dressings) & doesn't ask about food ingredients at restaurants or read labels. Case study #2 cont’d Case study #2 cont’d Food- & nutrition-related knowledge deficit (NB-1.1 ) R/T consuming hidden milk products AEB low BMI, mild diarrhea & diet Hx Case study #3 Mr. D. is a 73 y.o. white male admitted with leg fx after fall. He lives with his son and daughter in law. Per his son, Mr. D’s appetite has been poor the past 6 months, his dentures are very loose and he refuses to wear them. He also refuses pureed foods. Ht: 6 ft.; weight 133 lb; usual weight 1 year ago 165 lb. labs after hydration serum alb 2.4 g/dL; Hgb 10.6 g/dL, liver function tests Within normal limits (WNL). Case study #3 cont’d Case study #3 cont’d Chewing difficulty (NC-1.2) R/T ill-fitting dentures AEB diet history Increased energy expenditure (NI-1.2) R/T long bone fx AEB medical history Case study #4 95 y.o. female with dx HTN, constipation, severe low back pain, advanced cancer. She is on hospice care. Feeds himself then staff finish. Ongoing poor appetite. Ht- 167 cm Wt 55 kg, ↓7kg x 30 days. Diet: Pureed. Case study #4 cont’d Case study #4 cont’d Increased nutrient needs R/T increased demand for energy AEB significant wt loss 7kg