Livija Wells

NTR 417
Nutrition Care Plan Assessment
April 18, 2016

Social History:
Mrs. T is a 65-year-old Caucasian female currently residing in Latham, New York.
Mrs. T is living with her husband in a one story home with two dogs. Mrs. T works as a
receptionist at the Albany Stratton VA Medical Center. Aside from having a desk job,
Mrs. T is fairly active when it comes to walking her dogs around the neighborhood.
Between the client and her husband, they have enough income to live comfortably with
food and shelter. The clients mother passed away ten years ago and it still affects Mrs. T
as she has some depressive symptoms. Mrs. T is a recreational baker and is constantly
surrounded by sweets. The patient has no current history of alcohol or tobacco abuse but
will enjoy a few alcoholic beverages during the holidays. Mrs. T is 55 and 160 lbs.
Nutritional Implications: Mrs. T is an avid baker and is often tempted by her
treats. Her low active lifestyle can have effects on the symptoms of GERD. Also,
Mrs. T makes poor food choices when it comes to acidity, education of what types
of foods to avoid with GERD would be valuable to Mrs. T. Lastly with
depression, the patient can experience a loss/gain of appetite depending on her
medication which affects how the client eats. With GERD, the client should avoid
large high-fat meals.
Medical History:
Mrs. T was diagnosed with Gastroesophageal reflux disease (GERD) 6 years ago.
Prior to diagnosis, the patient did not pay attention to her diet and was hospitalized twice
for severe abdominal pain. Mrs. T did not undergo any surgery. Mrs. T was diagnosed
with depression 10 years ago and is receiving medication for it.
Nutritional Implications: Mrs. Ts ignorance to her diet will affect her nutritional
status, along with her depression medication. Mrs. T may not be getting the
enough of the right nutrients due to her poor eating habits, which can worsen her
effects of GERD, by creating more irritation in the lining of the esophagus. If
Mrs. T changes her diet by incorporating more healthy foods she will be able to
help her GERD and also lose excess pounds seeing as how she is overweight.

Diet History:
Mrs. T is currently consuming a regular diet, avoiding highly acidic foods. The
patient however does consume sweets fairly often seeing as how she is a frequent baker.
The patient has a good appetite despite her depression, she sometimes finds herself eating
less than she should. Mrs. T is often in distress after her meals due to being unaware of
how much acid is in her foods. Mrs. Ts diet averages at about 2,200 kcals per day.
Nutritional Implications: Mrs. T is consuming high-fat meals along with excess
acid in her foods. Her caloric intake is above what is necessary for her to maintain
her weight. Mrs. T is not receiving the proper nutrients she needs because shes
consuming energy-dense foods.
Medications:
Omeprazole is a proton pump inhibitor used to treat symptoms of gastroesophageal
reflux disease (GERD) and other conditions caused by excess stomach acid.
Nutritional Implications: can cause abdominal pain, nausea, and diarrhea.
Omeprazole can decrease absorption of iron, vitamin B12, and calcium. May be
taken with or without food.
Ranitidine is an H2 receptor that can treat and prevent heartburn. It can also treat
stomach ulcers, gastroesophageal reflux disease (GERD), and conditions that cause too
much stomach acid.
Nutritional Implications: can cause diarrhea and constipation. Ranitidine can
decrease absorption of iron and vitamin B12 and the absorption of antacids. May
be taken with or without food.
Sertraline is an antidepressant of the selective serotonin reuptake inhibitor (SSRI) class.
Nutritional Implications: can cause insomnia, dizziness, drowsiness and an
increase in sweating. Sertraline causes anorexia and a decrease in weight. May be
taken with or without food.

Pathophysiology:
Mrs. Ts currently presents problems of consistent heartburn and acid indigestion.
In Gastroesophageal reflux disease, the esophagus is irritated causing erosion in the
lining from ingesting highly acidic foods. The pathophysiology of GERD arises from
reduced lower esophageal sphincter (LES) pressure, inadequate esophageal tissue
defense, direct mucosal irritants, decreased gastric motility, and increased itraabdominal
pressure (Mahan, Escott-Stump, Raymond 2012). LES pressure can be induced by hiatal
hernia, scleroderma and Zollinger-Ellison syndrome, which is a hypersecretory disease.
The LES normally acts, combined with the diaphragm, as a barrier to prevent reflux of
stomach contents into the esophagus. If that barrier is compromised, reflux occurs.
Distension of the proximal stomach is a common precursor for GERD.
Symptoms of GERD include, heartburn, gastric secretions, belching, nausea or
regurgitation. Along with theses symptoms, due to chronic clearing of the throat, asthma
symptoms can arise. Mrs. T is familiar with these symptoms as she frequently complains
about heartburn and indigestion. As acid is exposed in the esophagus over time,
inflammation of the esophagus, or Esophagitis can occur (Mahan, Escott-Stump,
Raymond 2012). Other problems associated include esophageal erosions, ulceration,
scarring, stricture, and can sometimes lead to dysphagia. Frequent smoking can increase
the risk of esophagitis along with using aspirin for a long period of time. As GERD
progresses, it becomes severe and plays a role in daily activities such as sleep, work and
also social life and can also create an inadequate diet. An Inadequate diet can lead to
nutrient deficiencies, which can lead to chronic illnesses alongside having GERD.
It is said that hiatal hernia is a main contributor to GERD. Hiatal hernia is when
the stomach bulges through the diaphragm. The presence of a hiatal hernia increases the
risk complications associated with GERD. A hiatal hernia impacts the esophagus by
disrupting the attachment of the esophagus to the hiatal ring, which allows a portion of
the stomach to move the diaphragm (Mahan, Escott-Stump, Raymond 2012). Therefore,
as gastric juices occur from consumption, the contents remain in the esophagus longer
than usual. This results in worsening of esophagitis. Suggestions for improving the

amount of reflux can be as simple as sitting upright and eating smaller, more frequent
meals.
Medical treatment for GERD is primarily terminating acid secretion. This can be
done with use of certain medications such as proton pump inhibitors, and/or H2 receptors,
Mrs. T uses both PPIs and H2 blockers. Proton pump inhibitors are responsible for
decreasing the production of acid for an extended amount of time. They are the most
potent inhibitors of acid secretion, making proton pump inhibitors the common treatment
for conditions such as GERD. H2 blockers reduce the production of stomach acid, and
allow the esophagus to heal. Most importantly, patients with GERD should be aware of
how much acid they consume and make sure to avoid large, high-fat meals.
Assessment:
Mrs. T is at risk for worsening her symptoms of GERD if she continues to
disregard her intake of highly acidic foods. The acid will cause reflux and discomfort to
the patient. If her symptoms worsen, she may be qualified to undergo fundoplication, a
procedure in which the fundus of the stomach is wrapped around the esophagus and sewn
into place so that the lower portion of the esophagus passes through a portion of the
stomach muscle.
Mrs. T is currently 28% above her IBW and her BMI is 26.6, which is classified
as overweight. Her caloric needs are 2,009 kcals per day in order to maintain her weight.
In order to lose weight at a healthy rate, Mrs. T would need to deduct 500 calories per
day from her caloric needs in order to lose a pound a week (3,500 kcals). Mrs. T also
needs to include more physical activity in her day aside from walking her dogs. Walking
during breaks at work or doing little tasks to increase amount of steps per day is a
feasible task to help decrease her severity of GERD.
NB- 1.1 Food- and nutrition- related knowledge deficit related to, regular
consumption of highly acidic/high-fat meals, as evidence by diagnosis of GERD.

Intervention:
Provide ~ 2000 kcals per day to meet caloric needs. Reduce by 500 kcals daily to lose a
pound a week.
Education: Inform patient on acidic and high-fat foods. Also, inform patient on guidelines
for reducing symptoms of GERD (eating at least 2-4 hours before lying down, avoid
smoking an alcohol, sitting upright, etc.).
Meals & Snacks: Obtain Mrs. Ts food preferences and make small adjustments to better
suite her lifestyle. Limit snacking, and large high-fat meals. Have the patient consider
eating smaller more frequent meals throughout the day. Monitor her food intake via
weekly food diary to make sure the appropriate foods are being avoided and calorie dense
foods are being added.
Physical activity: Have the patient engage in more physical activity, about 30-60 minutes
each day.
Monitoring & Evaluation:
Short Term Goals
1. PO intake to meet > or = 75% of estimated calorie needs within 14 days.
2. Reduce fat intake by 20 grams a day for 7 days.
Long Term Goals
1. Prevent further damage to esophageal lining via eliminating large, acidic, highfat meals.
2. Weight to drop 5% of current weight.

References:
Mahan, L. K., Escott-Stump, S., Raymond, J. L., & Krause, M. V. (2012). Krause's food
& the nutrition care process. St. Louis, MO: Elsevier/Saunders.
Pronsky, Z. M., & Crowe, J. P. (2010). Food medication interactions. Birchrunville,
Penn.: Food-Medication Interactions.