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 FH AD BD PD CH eats 2x meals a day, fried foods, burgers, ice cream, beers in restaurant. No salt to foods. AD ht: 5 ft. 10 in; wt: 250 lb; BMI 36, obesity II BD PD CH 34 y.o. male Htn, DM2, hyperlipidemia Patient works night shift

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 FH AD BD PD CH Fatigue; GI wt=114 lb; ht= 5'6" Consumes hidden milk products doesn’t read labels & ask about food Ingredients AD wt=114 lb; ht= 5'6" BMI=18 BD PD Fatigue; GI distress CH 50 y/o female; Milk allergy; Chronic mild Diarrhea after meals

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 FH pureed foods AD Ht: 6 ft.; weight 133 lb; usual weight 1 year ago 165 lb BD serum alb 2.4 g/dL; Hgb 10.6 g/dL, liver function tests WNL. PD appetite has been poor CH 73 y.o. white male admitted with leg fx after fall. He lives with his son wear dentures

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 Diet: Pureed. FH Diet: Pureed. AD Ht- 167 cm Wt 55 kg, ↓7kg x 30 days BD PD CH 95 y.o. female with dx HTN, constipation, severe low back pain, advanced cancer. He is on hospice care.

Case study #4 cont’d Increased nutrient needs R/T increased demand for energy AEB significant wt loss 7kg x 30 days, cancer, hospice care

Case study #5 55 y.o. female admitted with Hypertension. Height 165 cm weight 77kg. 24 hour recall showed that her consumption from sodium higher than RDA recommendation. Nutrition history: has been told to weigh self daily but has no scale at home. Does not add salt to foods at the table. Noticed swollen face and extremities on day prior to admission. Day before admission ate canned soup for lunch and 3 slices of pizza for dinner; has never received nutrition counseling

55 y.o. female admitte with Htn Case study #5 cont’d FH sodium higher than RDA. Does not add salt to foods at the table ate canned soup for lunch and 3 slices of pizza for dinner AD Ht 165 cm wt 77kg BD PD swollen face CH 55 y.o. female admitte with Htn

Case study #5 cont’d Food- & nutrition-related knowledge deficit (NB-1.1 ) R/T no previous nutrition education AEB frequent use of high sodium convenience foods. Food- & nutrition-related knowledge deficit (NB-1.1 ) R/T consuming products contain high salt AEB 24 hour recall and diet history.

Case study #6 99 y.o. female with depression, lactose intolerance. She reports her appetite isn’t good lately. Meal intake records also show a decline. She feeds herself, Ht- 159 cm, Wt 48,↓11kg x 30 days.

Case study #6 cont’d FH Meal intake records also show a decline AD Ht- 159 cm, Wt 48,↓11kg x 30 days BD PD appetite isn’t good lately CH 99 y.o. female with depression, lactose intolerance

Case study #6 cont’d Inadequate oral food and beverage intake (NI-2.1) R/T intake less than calorie expenditure AEB diet history, significant wt loss 11kg x 30 days, and decreased appetite.