Nutrition Prescription (The patients/clients individualized recommended dietary intake of energy and/or selected foods or nutrients based on current

reference standards and dietary guidelines and the patients/clients health

condition and nutrition diagnosis): Nutrient Needs: Kcals: 1,813-2,175 kcals/d, Fluids: 1500 ml/d, Protein: 73-80 g/d (Kcals: 25-30 kcals/kg of upper IBW of 72.5 kg.), (Fluids: CHF fluid restriction recommendations as
evidenced in Nelms, Sucher, Lacey, & Roth (2011)), (Protein: 1.0-1.1 g/kg (older adult maintenance) of upper IBW of 72.5 kg).

Assess Priority Diagnosis (PES Statement) Intervention Monitoring Evaluation

Interpret data needed to identify nutrition related ______RT______ AEB_______ What are you going to do to fix the problem? What data do you need to assess Quantifiable goal(s)
problems, their causes, and significance your intervention?
Client Information: ID is a 77 y.o. African 1 Excessive mineral intake (sodium) Nutrition Education: Educate patient on low- Nutrient Intake: Sodium content In 1 month:
American male. ID was admitted to the acute care RT typical consumption of high- sodium dietary guidelines and on recommended 2 of food choices via monitoring of 3-day food records indicating
unit w/ acute chest pain, acute exacerbation of CHF, sodium foods AEB acute g Na diet associated w/ heart failure. 3-day food record reduced intake of high-sodium
SOB, atrial fibrillation, HTN, and macrocytosis. exacerbation of CHF and dietary foods
recall that reflects consumption of
Subjective Assessment: Patient reported that he lives foods high in sodium, such as
with his wife, has a UBW of 260#, and that his mashed potatoes and gravy,
weight has been stable in the last year. Patient reports cornbread, sausage, and toast.
that he does not smoke and that he only drinks
alcohol occasionally, a few times a year. 2 Decreased nutrient needs (fluid) Nutrition Education: Educate patient on Nutrient Intake: Daily fluid By next review in 3-5 days:
RT heart failure AEB acute recommended daily intake levels of fluid for intake via 24-hr. recall Intake of 1500 ml fluids/d per 24-
Dx: Acute exacerbation of CHF exacerbation of CHF and fluid maintenance of heart failure. Demonstrate hr. recall
restriction of 1500 ml/d. recommended intake of 1500-2000 ml fluid/d
PMH: CHF, HTN, DM, diabetic neuropathy, thyroid using measuring cups.
disease

Objective/Assessment:
Anthropometrics:
Ht: 170 cm/5 ft. 7 in., Wt: 117 kg/257.9#., BMI: 40.5 3 Altered nutrition-related laboratory Meals and Snacks: Diet order changed to Low Nutrient Intake: Intake of kcals By next review in 3-5 days:
(Obese, class III, high-risk), IBW: 65.9 kg/145# and values RT impaired endocrine sodium 2 gm Na diabetic (carb consistent) diet w/ and carbs via 24-hr. recall Intake of 1800 kcal/d w/
178% IBW, UBW: 118 kg/260# and 99% UBW, and function 2/2 dx of T2DM AEB 1500 ml/d fluid restriction. Provide patient with recommended amounts of
1% wt change in last year (stable wt) Gluc 128 (H), and Accu-Check BG CHO Exchanges based on 1800 kcal ADA consistent carbs per 24-hr. recall
101-192 (H). diabetic diet.
Biochemical: Lab Values: Gluc & Accu-Check Gluc and Accu-Check BG of 70-
Labs 1/30: WBC 3.7 (L), K+ 5.3 (H), Gluc 128 (H), BG 110 mg/dL
AG 5.0 (L), Accu-Check BG 101-192 (H)

Clinical:
General Appearance: Patient appears well-nourished
and overweight.
Physical Findings: Patient reports skin is dryer than
normal, has dentures on top that fit well, and has
original teeth on bottom. Patient is missing one tooth
on bottom row, skin is intact, and has no S/S of
possible swallowing disorder.
Social History: Patient eats meals w/ wife, doesnt
smoke, and consumes alcohol occasionally. Patient
says is wife prepares his meals at home.
Current Meds:
Atorvastatin
Lisinopril
Insulin apart, subcutaneous injection prn
hyperglycemia

Dietary:
Intake: Patient reports good appetite level, intake of
75% of daily meals. Dietary recall including
typical foods, such as scrambled eggs, milk, coffee,
sausage, toast, string beans, baked chicken, mashed
potatoes and gravy, and cornbread,
Current Diet Order: Low-sodium 2 gm Na w/ 1500
ml/d fluid restriction.

Reference

Nelms, M., Sucher, K. P., Lacey, K., & Roth, S. L. (2011). Chapter 17: Diseases of the endocrine system. Nutrition therapy & pathophysiology (pp. 471-519). Belmont, CA: Brooks/Cole Cengage Learning.