Cheathem_D_NAM_1.1.b.

1_CVD_NCP

Nutrition Prescription: Therapeutic Diet – Sugar in Moderation to provide 1,814 kcal/day (MSJ w/o Activity Factor for Weight Loss), 82 gm/day of protein (18% of estimated
energy needs), 227 gm/day of carbohydrates (50% of estimated energy needs), and 1,814 mL of fluid (1mL/kcal).
Assess Priority Diagnosis Intervention Monitoring Evaluation
FOOD/NUTRITION-RELATED HISTORY
Food & Nutrient Intake: Pt reports that his
typical diet consists of fast food items and
fired foods.
Food and Nutrient Administration: 2 Week
Current diet order: TLC-SIM Diet Nutrition Education Outpatient
Medication and CAM: (E) Follow-up
Cordarone QD
Aspirin QD Nutrition Education – -Monitor pt
-Pt will be able to
Zebeta WD Food and nutrition Content (1) understanding of
list three specific
Lasix 5x/weekly related knowledge -Provide the patient DASH Diet instructions of the
Atroven BID deficit RT lack of with DASH Diet InstructionsDASH diet with
Xopenex BID exposure or handout and 100% accuracy.
Singulair QD exposure to instructions. -Monitor pt -Pt will be able to
Azo QD inaccurate nutrition- -Educate patient onunderstanding of Low identify three
Ocean Nasal Spray PRN 1 related information appropriate low Sodium snack/food appropriate snack
Turmeric Oral QD AEB the patient sodium snack/ options. or food options that
Knowledge/Beliefs: Pt verbalizes that he verbalizing non- food options. are low in sodium
knows that he needs to eat better to improve compliance and lack -Monitor pt with 100%
his blood pressure and other conditions. of knowledge about Nutrition understanding of accuracy.
Behavior: Per observation of the discussion heart healthy eating Relationship to positive diet choices -Pt will be able to
with the pt, the pt appears to be accepting patterns. Disease and the effects on discuss two
and receptive for recommendations of diet -Explain the effect of heart health. positive effects that
modifications. a positive diet & heart a healthy diet can
Factors Affecting Access to Food and health have on heart
Food/Nutrition-Related Supplies: N/A health.
Physical Activity: Patient reports a
sedentary lifestyle.
ANTHROPOMETRIC MEASUREMENTS
Height: 5’9” Weight: 105.5kg
UBW: 105.5 kg % UBW: 100%
Cheathem_D_NAM_1.1.b.1_CVD_NCP
IBW: 73 kg % IBW: 145%
BMI:34.36 kg/m2 No wt change
observed
BIOCHEMICAL DATA, MEDICAL TESTS,
AND PROCEDURES
Lab data:
Potassium: 4.6 mEq/L ✓
CO2: 39 mEq/L ­
Creatinine: 1.03 mg/dL ✓ 2 Week
BUN: 23 mg/dL ✓ Nutrition Education Outpatient
GFR: 73 mL/min/1.73m2 ¯ (E) Follow-up
-Monitor pt
Glucose: 102 mg/dL ✓ understanding of -Pt will be able to
Tests: EKG, Cardia Telemetry Nutrition Education – DASH Diet list three specific
NUTRITION-FOCUSED PHYSICAL Content (1) Instructions instructions of the
FINDINGS -Provide the patient DASH diet with
Per NFPE, the patient is overweight and has Overweight RT food with DASH Diet 100% accuracy.
and nutrition knowledge -Monitor pt
centralized adiposity. No signs of muscle or handout and understanding of Low -Pt will be able to
deficit AEB body mass
fat wasting was observed. 2 index of 34.36 and instructions. Sodium snack/food identify three
CLIENT HISTORY patient verbalization of -Educate patient on options. appropriate snack
Reason for Admission/Assessment: The lack of knowledge about appropriate low or food options that
patient was recently admitted into the healthy eating patterns. sodium snack/food are low in sodium
-Monitor pt
hospital for his fourth CABG procedure. options. with 100%
understanding of
Personal History: Patient C.B. is a 52 year accuracy.
positive diet choices
old Caucasian male who speaks English and Nutrition -Pt will be able to
and the effects on
has the family role of a husband and father. Relationship to discuss two
heart health.
Patient/Client/Family Medical/Health Disease positive effects that
History: -Explain the effect of a healthy diet can
-Pt Medical Hx: Hernia, Kidney Infarction, a positive diet & heart have on heart
Heart Failure, COPD, DVT, Sleep Apnea health health.
-Family Medical Hx: Heart Disease, Heart
Treatments/Therapy: S/P CABG x 4, Hernia
Repair
Social History: Former Smoker – 1
pack/day for 47 years with quit date of
1/1/2018. No reported drug or alcohol
abuse.