Case Study

NDFS 4550
McKenna Heller
Fall 2019
Case Introduction

EW was a 23 year old Caucasian female who grew up in a middle class family in Kaysville, Utah.

EW gave consent to be referred to in this case study by the pronouns her/she. The patient’s family

consisted of a mother, father, and 3 siblings. EW was the oldest of the three siblings. The patient had a

younger brother and two younger sisters. The patient’s mother cooked well-balanced meals for EW’s

family growing up. EW’s mother did not diet or promote weight loss while EW was growing up. The

patient self-identified as somewhat introverted socially. In high school the patient participated in

athletic events and was a sprinter on the school’s track team. The patient’s coaches encouraged EW to

eat a balanced diet and practice body-love. After graduation the patient began attending school at Utah

State University. After attending a couple semesters of school EW served a full time proselyting mission

for the Church of Jesus Christ of Latter Saints in Mexico. After returning home from serving a mission EW

began attending school at Utah State University again. The patient was a Junior in the Coordinated

Program of Dietetics there.

Six months before being admitted to the hospital for sepsis EW was married. The patient lived

an active lifestyle. The patient enjoyed spending time with family, camping, paddle boarding, hiking,

running, reading, play board/card games, cooking, and eat new things. The patient had allergies to

shellfish, aspirin, and ibuprofen (hives). About 80% of EW’s meals with eaten with another person.

Over spring break EW was playing beach volleyball. While playing volleyball EW’s right dorsal

was lacerated. The laceration continued to get worse despite antibiotic treatment and eventually led to

a right dorsal amputation. Patient continued to do poorly and became septic. While being admitted in

the hospital EW experienced cardiac arrest and was successfully resuscitated. The patient experienced

two more attacks of cardiac arrest while in the ICU. The patient was discharged after two weeks and was

given a heart healthy diet to follow. Patient was given lifestyle changes education and instructed to

adopt a therapeutic lifestyle changes (TLC) diet.

Literature Review

While playing volleyball on the beach the patient received a laceration on the right foot. The

laceration the patient sustained became infected which eventually caused the patient to become septic.

“Sepsis is the body’s overwhelming and life-threatening response to infection which can lead to tissue

damage, organ failure, and death.”1 While fighting the infection the patient’s immune system responded

in a way which caused damage to the patient’s organs, specifically her heart. 2 Sepsis is an immune

response to infection.1 When sepsis occurs blood flow throughout the body is inhibited. 2 This results in

damage to vital organs, even organ failure. 2 The heart is affected specifically “by release of cytokines,

mitochondrial dysfunction, and tissue hypoxia” that sepsis causes which “leads to cardiac myocyte injury

and death.”3 On day 5 of being admitted to the hospital EW suffered cardiac arrest and was successfully

resuscitated on the first attempt. EW’s development of sepsis damaged the heart which resulted in

heart failure. A recently published study found that individuals who had experienced “severe sepsis and

septic shock” were more likely to experience a heart attack or stroke shortly after treatment. 3 Within 7

days after discharge from a hospital 26% of study participants suffered from either a heart attack or

stroke.1 Septic survivors continue to have an increased risk for experiencing cardiovascular related

health issues over time.5

Symptoms of sepsis include decreased urination, “difficulty breathing”, confusion and loss of

consciousness, fluid retention resulting in bloating, or having a “higher or lower [temperature] than

normal.”1 Those at risk for developing sepsis include those who have any kind of infection, even

something as small as a hangnail.1 Individuals who are “very young [or]… very old,” have a chronic

disease or illness, or who are immunocompromised are at increased risk for incidence of sepsis. 1
Nutrition Assessment

Anthropometrics

Anthropometric measurements of the patient were taken to comparative against normative

data for individuals of similar age and gender . 5,6,7

Table A8

Measure Value Interpretation

Weight (Pre-amputation) 58.9 kg 25th percentile according to the 2007-2010 NHANES
data
Adjusted Body Weight (right 58.02 kg 25th percentile according to the 2007-2010 NHANES
dorsal amputation) data
Adjusted Usual Body Weight 58.02 kg 25th percentile according to the 2007-2010 NHANES
(UBW) data
Height 167.5 cm 75th percentile according to the 2007-2010 NHANES
data
BMI 21 Healthy
Wrist circumference 16.5 cm According to Medline, medium wrist circumference
for height
Frame size 48 mm According to Medline, medium frame size for height
Desirable weight 56.7 kg This is according to the Hamwi Formulation.
Mid-arm circumference 27.75 cm 25th percentile according to the 2007-2010 NHANES
data.
Triceps skinfold 15 mm 15th percentile according to the 2007-2010 NHANES
data
Subscapular skin fold 12 mm 25th percentile according to the 2007-2010 NHANES
data.
Quadriceps skin fold 16 mm
Waist measurement 73.5 cm 10th percentile according to the 2007-2010 NHANES
data.
Waist-to-Height ratio 44.62% According to PennState Pro Wellness, healthy
weight
% Body fat 18.4% Athlete
Calf circumference 36.5 cm According to MyFitnessPal, average for a woman.
Blood pressure 112/78 Slightly low
Resting energy expenditure 1,366 cal Expenditure according to the Mifflin-St. Jeor
predictive equation.
Knee height 51 cm Normal knee height for height
Grip strength R: 28 kg Average grip strength for a woman.
L: 30 kg

%UBW:
Current weight/adjusted UBW= %UBW

58.02 kg/ 58.02 kg= 100% UBW

EW is 100% her UBW.

% IBW: Hamwi Formula12

106 lbs for first 5 feet + 6 lbs for each additional inch over 5 feet= Ideal Body Weight

106 lbs + 6 lbs (6 inches)= 142 lbs = 64.41 kg

64.41 x 1.5% = 63.55 kg = Adjusted IBW

Current weight/IBW= (58.02 kg/63.55 kg) x 100= 91.30% IBW

EW is 91.30% her IBW.

The patient’s anthropometric measurements remained consistent over time, except for weight. EW’s

weight decreased because of the patient’s foot was amputated. Other than weight loss because of the

amputation, EW did not experience weight loss or weight gain within the past 6 months.

Comparative quadricep skin fold data was not able to be found. Based off of other anthropometric

measurements, EW’s quadricep skin fold measurement likely would have fallen within the 10 th and 25th

percentile on comparative charts.

Biochemistry

Table B

Lab Admit Normal values Interpretation

Hgb 9.8 12-16 Low

Hct 35 36-46 Low
MCV 76 80-100 Low
Albumin 2.8 3.5-5 Low
T. Pro 6.3 6-8 Normal
Prealbumin 15 16-35 Low
CRP 3 <7 Normal
Transferrin 385 250-380 (women) High
215-365 (men)
Ferritin 15 20-120 Low
Sodium 133 136-145 Low
Potassium 3.8 3.5-5.5 Normal
Chloride 99 95-105 Normal
 Total CO2 25 23-30 Normal
BUN 16 8-18 Normal
Creatinine 1.2 0.6-1.2 Normal
Bilirubin 0.9 <0.3 High
ALT 115 4-36 High
AST 85 0-35 High
AlkPhos 200 30-120 High
HgbA1C 4.2 3.9-5.2 Normal
PT 19 11-16 High
Magnesium 1.2 1.8-3 Low
Cholesterol 210 120-199 High
LDL 136 <130 High
HDL 30 >45 Low

Lab values that were low for the patient included HgB, Hct, MCV, albumin, prealbumin, ferritin, sodium,

magnesium, and HDL cholesterol.

Lab values that were high for the patient included transferrin, bilirubin, ALT, AST, AlkPhos, Cholesterol,

and LDL cholesterol.

Sodium levels were low, potentially due to the patient’s heart failure and subsequent water retention in

ascites in the abdomen.10

Low hemoglobin, ferritin, and MCV values combined with high transferrin levels indicated the patient

was experiencing iron deficiency anemia. Iron would have been appropriate to give the patient. 10 A 3-

day average nutrient analysis of the patient’s diet following discharge indicated the patient began

consuming adequate amounts of iron.

High bilirubin levels indicated the patient’s liver may have been damaged and was not filtering blood

efficiently.10 This may have been reflective of damage sustained by the liver while patient was septic. 2

Elevated total cholesterol and LDL cholesterol together with low HDL cholesterol values indicate patient

was at risk for heart disease.

 Alanine transaminase (ALT) and aspartate aminotransferase (AST) lab values were significantly higher

than normal, which indicated the patient had liver damage. 10

Clinical/Nutrition Focused Physical Exam

Table C

System Noted Complications

Overall Health Generalized malaise, foot amputation, cardiac
arrest.
Ears, Nose, Mouth, & Throat No problem
C-V (Heart and Blood Vessels) Heart failure; heart murmur; high blood pressure;
quick heart rate; enlarged heart (cardiomegaly)
Resp. (Lungs & Breathing) Abnormal lung sounds heard in back side of each
lung
GI (Stomach & Intestines) Water accumulation (ascites) in abdomen.
GU (Kidney & Bladder) No problem
MS (Muscles, Bones, Joints) Right foot amputation
Integ. (Skin, Hair, & Breast) Skin was pale, gray and moist; pitted edema
present in patient’s extremities

Malnutrition Universal Screening Tool (MUST)13

Step 1 (score: 0)

Height: 167.5 cm

Weight: 58.02 kg

BMI: 21

Step 2: (score: 0)

<5% unplanned weight loss in past 3-6 months

Step 3: (score: 0)

Step 4: (total score: 0)

Low Risk (routine clinical care)

Patient was acutely ill but was able to continue nutrition intake throughout duration of illness. Patient

was not determined to be malnourished.

Table D
 Medication Dosage
Lanoxin 0.25 mg daily
Lasix 80 mg x 2 daily
Multivitamin X 2 daily
Lopressor 25 mg daily
Zocor 20 mg daily
Calcium carbonate 500 mg x 2 daily
Metamucil prn (as needed)
Aldactone 25 mg daily

Lanoxin was used to treat the patient’s heart failure. 14 Lasix was used to treat the patient’s fluid

retention and reduce edema caused by heart failure. 14 Lasix has a moderate drug interaction with

alcohol which causes decreased blood pressure. 14 Lanoxin and Lasix were prescribed to treat the

patient’s short term health condition. Lopressor was prescribed to EW to treat high blood pressure and

has moderate drug interactions with alcohol, multivitamins with minerals, food, and high cholesterol. 14

Consuming alcohol while on Lopressor causes lowered blood pressure. 14 Taking multivitamins while on

Lopressor may caused lowered blood pressure, slow heart rate, and decrease the drugs effectiveness. 14

Taking Lopressor with food increases the bioavailability of Lopressor. 14 Lopressor can increase VLD/LDL

cholesterol and triglyceride levels. HDL cholesterol levels may decrease. Lopressor was given to treat an

underlying incidence of high blood pressure in the patient. Zocor was given to the patient to decrease

serum levels of triglycerides/LDL cholesterol and increase HDL cholesterol to decrease risk of stroke and

heart attack. Zocor has a major interaction with grapefruit juice. Grapefruit juice consumption increases

bioavailability of Zocor and result in liver damage and rhabdomyolysis. Zocor was prescribed to treat the

patient’s chronic hypercholesterolemia. Calcium carbonate aids the heart in maintaining a proper

rhythm.15 The patient would have needed to take continue taking chronically because of the heart

damage that occurred.15 Metamucil is a fiber based bulking laxative. Metamucil was given to aid in

lowering the patient’s cholesterol levels. This medication was prescribed to treat the patient’s chronic

condition of hypercholesterolemia. Metamucil can decrease other drugs effectiveness. Aldactone is a

 laxative that keeps potassium levels normal in patients and reduces edema. When Aldactone is taken

with alcohol decreased blood pressure may result. This medication was given to treat the patient’s

current illness.

Diet Evaluation

Table E

Breakfast Lunch Dinner Snacks

Day 15 2 cup Cheerios, 1 5 oz pesto 5 small corn 0.2 cups carrots,
cup unsweetened chicken, 0.8 cup tortillas, 0.3 cup 0.2 cups celery, 2
almond milk, 1 quinoa (dry), 1 cheese, 0.2 ea mozzarella string
banana cup grapes avocado, 1 svg cheese sticks, 1
roasted svg smoothie
asparagus, 0.5 cup
carrots
Day 18 0.5 cup oats (dry), 0.5 cup cucumber, 6 small corn 1 peanut butter
1 tsp honey, 1 1 cup carrots, 5.3 tortillas, 0.5 cup bar, 3 slices whole
Tbsp peanut oz Greek vanilla black beans, 0.5 wheat bread, 3
butter (creamy), 1 nonfat yogurt cup romaine Tbsp Nutella, 1
banana lettuce, 4 oz taco svg smoothie, 1
chicken, 4 oz pico Tbsp chia seeds
de gallo
Day 22 2 cup Cheerios, 1 1 cup 1% cottage 20 fl-oz 2% vit A & 1 orange, 1 cntr
cup unsweetened cheese, 1.5 cup D milk, 12 oz Greek vanilla
almond milk cucumber, 0.5 cup enchilada soup nonfat yogurt, 1
celery, 0.5 cup banana, 1 cup
carrots, 3 slices spinach, 3 Tbsp
whole wheat ground flax
bread seed,1Tbsp chia
seeds, 1 tsp
cinnamon

Table F

Anthropometric Measurement
Weight 58.02 kg
Height 167.5 cm
Age 23
Activity Factor (AF) 1.55 (mild activity level)

Harris-Benedict Equation9:
BMR= (655.1 + (9.563 x weight in kg) + (1.850 x height in cm) – (4.676 x age in years)) x AF

BMR= (655.1 + (9.563 x 58.02 kg) + (1.850 x 167.5 cm) – (4.676 x 23)) x 1.55 = 2189.02 calories

The patient’s calorie needs according to the Harris-Benedict Equation was 2189.02 calories per day,

which was just 10.36 calories more than the calorie recommendation given by ESHA Trak. The patient

had a mild activity level, exercising for about 30 minutes twice per week.

Table G

Nutrients Average Eaten Target Status

Total Calories 2,209.94 2,178.66 Ok
Calories Calories
Protein (g) 112.66 (g) 48.99 (g) Ok
Protein (% Calories) 10-35% Calories 20.39% Ok
Carbohydrates(g) 323.74 (g) 299.57 (g) Ok
Dietary Fibers (g) 51.80 (g) 30.50 (g) Ok
Total Sugars (g) 121.24 (g) No Daily No Daily Target
Target or or Limit
Limit
Added Sugar (g) 14.79 (g) <27.23 (g) Ok
Total Fat (g) 63.66 (g) 67.78 (g) Under
Saturated Fat (g) 12.95 (g) <21.79 (g) Ok
Monounsaturated 16.21 (g) 24.21 (g) Under
Fat (g)
Polyunsaturated Fat 11.11 (g) 21.79 (g) Under
(g)
Cholesterol (mg) 121.81 (mg) <300.00 (mg) Ok
Water (ltr) 1.40 (ltr) 2.70 (ltr) Under
Vitamins Target Average Status
Eaten
Thiamin (mg) 1.97 (mg) 1.10 (mg) Ok
Riboflavin (mg) 2.45 (mg) 1.10 (mg) Ok
Niacin (mg) 29.52 (mg) 14.00 (mg) Ok
Vit B6 (mg) 3.84 (mg) 1.30 (mg) Ok
Vit B12 (mcg) 4.66 (mcg) 2.40 (mcg) Ok
Vit C (mg) 121.23 (mg) 75.00 (mg) Ok
Vit D (mcg) 7.51 (mcg) 15.00 (mcg) Under
Vit K (mcg) 231.38 (mcg) 90.00 (mcg) Ok
 Vit E (mg) 19.61 15.00 Ok
Folate (mcg DFE) 1,157.76 (mcg 400.00 (mcg Ok
DFE) DFE)
Vit A (mcg) 1,537.72 (mcg) 700.00 (mcg) Ok
Minerals Target Average Status
Eaten
Calcium (mg) 2,005.55 (mg) 1,000.00 (mg) Ok
Copper (mg) 1.42 (mg) 0.90 (mg) Ok
Iron (mg) 22.18 (mg) 18.00 (mg) Ok
Magnesium (mg) 490.98 (mg) 310.00 (mg) Ok
Phosphorus (mg) 1,761.00 (mg) 700.00 (mg) Ok
Potassium (mg) 4,142.75 (mg) 2,600.00 (mg) Ok
Selenium (mcg) 74.12 (mcg) 55.00 (mcg) Ok
Sodium (mg) 1,842.38 (mg) <2,300 (mg) Ok
Zinc (mg) 14.64 (mg) 8.00 (mg) Ok
Other Nutrients Target Average Status
Eaten
Linoleic Acid (g) 6.30 (g) 12.00 (g) Under
Linolenic Acid (g) 0.56 (g) 1.10 (g) Under
Omega 3- EPA (g) 0.00 (g) No Daily No Daily Target
Target or or Limit
Limit
Omega 3- DHA (g) 0.02 (g) No Daily No Daily Target
Target or or Limit
Limit
Choline (mg) 281.14 (mg) 425.00 (mg) Under
Alcohol (g) 0.00 No Daily No Daily Target
Target or or Limit
Limit

An analysis of the patient’s 3-day food log showed EW did not need the recommended intake of

the following nutrients: total fat, monounsaturated fat, polyunsaturated fat, water, vit D, linoleic acid,

linolenic acid, and choline.

While being admitted to the hospital the patient was experiencing iron deficiency anemia. The

TLC diet the patient adhered to following discharge provided the patient mostly plant-based sources of

iron. Non-heme iron is less bioavailable and is therefore absorbed less efficiently than heme iron.

Considering this, the patient may not have been meeting her recommended iron intake. The patient also
did not meet her recommended fat intake. This may have caused fat soluble vitamins A, D, E, and K to

be absorbed less efficiently. EW may not have been absorbing as many of the fat soluble vitamins as her

body needed and may have been deficient in these vitamins while following the TLC diet.

The patient felt overwhelmed beginning the diet because of the nutrient tracking that was required. EW

felt like the dietitian giving her nutrition education did not give sufficient details to enable to her to feel

like she could succeed in following the diet. During the diet the patient ate out and did not follow the

TLC diet. EW had difficulty eating the recommended fruit, vegetable and whole grain servings

consistently throughout the day. The patient ended days often times eating lots of fruits, vegetables,

and whole grains before bedtime to meet the days nutrient requirements. The patient felt the diet was

restrictive and craved foods that were restricted by the diet. The patient did not want to continue eating

the recommended servings of vegetables but continued to follow the vegetable recommendations for

14 days.

Nutrition Care Plan

Intervention

Following the incidence of sepsis and heart failure in the patient a dietitian was prescribed to

educate EW about following a Therapeutic Lifestyle Change (TLC) diet. 17 A TLC diet combined with

exercise and medication has been shown to decrease serum levels of LDL and total cholesterol while

increasing serum levels of HDL cholesterol. 17,18

The patient was instructed to begin adhering to a TLC diet immediately following discharge from

the hospital. The patient met with a registered dietitian (RD) for 20 minutes and was given education

about the TLC diet. The patient was given a list of foods to eat and foods to avoid. A sample meal plan
was given to the patient. The afore mentioned materials and resources were given to EW to assist EW in

following the meal plan.

Monitoring/Evaluation

During the follow-up with the patient 14 days after discharge 2 SMART goals were identified for

the patient. The patient had a difficult time incorporating 8-10 servings of fruits into her diet during the

day and would consume several servings of fruits/vegetables in the evening before bed time in order to

consume all the remaining servings of fruits/vegetables recommended for the day. The patient

identified this occurrence as an area for improvement to occur. Goal 1 was created by the patient and

dietitian for the purpose of increasing the patient’s consumption of fruits/vegetables throughout the

day so the patient would not have to eat many servings of fruits/vegetables in the evening. Eating

fruits/vegetables more regularly throughout the day will increase EW’s adherence to the diet. Greater

adherence to the TLC diet will increase the health benefits associated with adherence to the diet. 19

ADIME

Assessment Code: Estimated meal and snack pattern (FH-1.2.2.3.1)

Diagnosis: Food and Nutrition Related Knowledge Deficit (NB-1.1) related to EW’s lack of knowledge of

the TLC diet. EW has “limited prior nutrition-related education” and experienced “uncertainty [of] how

to apply nutrition information” evidenced by her inconsistent intake of fruits, vegetables, and whole

grains throughout the day.20

PES Statement: Food and Nutrition Related Knowledge Deficit (NB-1.1) related to EW’s uncertainty of

how to apply nutrition information as evidenced by Intakes of Types of Carbohydrate Inconsistent with

Needs (NI-5.8.3) (specifically related to fruit, vegetables, and whole grains).

Intervention Term/Code: Nutrition related skill education (E-2.2) The patient received education from an

RD about meal planning. EW felt that if she began meal planning her intake of fruit, vegetables, and

whole grains throughout the day would be more consistent.

Monitoring Term/Code: Estimated meal and snack pattern (FH-1.2.2.3.1)

Evaluation Plan

Patient Goal: Patient will meal plan at least one day in advance all meals/snacks. EW planned to

consume at least 9 servings of fruits/vegetables by the end of dinner.

RD followed up with the patient 14 days after discharge from the hospital. 21 Incidence of “heart failure

exacerbation” and related problems are less likely to occur in patients who receive early follow-up care

14 days after being discharged from the hospital. 21 RD and EW discussed the patient’s adherence to the

prescribed TLC the patient had been following. A 14 day food log was kept by the patient and a nutrient

analysis was done by the RD to check for nutritional completeness and adherence to TLC diet. If patient

was not following the diet the RD was prepared to discuss a step-wise plan to implement aspects of the

diet over time until the patient would eventually be following a full TLC diet.
Appendix

Table A

Measure Value Interpretation

Weight (Pre-amputation) 58.9 kg 25th percentile according to the 2007-2010 NHANES
data
Adjusted Body Weight (right 58.02 kg 25th percentile according to the 2007-2010 NHANES
dorsal amputation) data
Adjusted Usual Body Weight 58.02 kg 25th percentile according to the 2007-2010 NHANES
(UBW) data
Height 167.5 cm 75th percentile according to the 2007-2010 NHANES
data
BMI 21 Healthy
Wrist circumference 16.5 cm According to Medline, medium wrist circumference
for height
Frame size 48 mm According to Medline, medium frame size for height
Desirable weight 56.7 kg This is according to the Hamwi Formulation.
Mid-arm circumference 27.75 cm 25th percentile according to the 2007-2010 NHANES
data.
Triceps skinfold 15 mm 15th percentile according to the 2007-2010 NHANES
data
Subscapular skin fold 12 mm 25th percentile according to the 2007-2010 NHANES
data.
Quadriceps skin fold 16 mm
Waist measurement 73.5 cm 10th percentile according to the 2007-2010 NHANES
data.
Waist-to-Height ratio 44.62% According to PennState Pro Wellness, healthy
weight
% Body fat 18.4% Athlete
Calf circumference 36.5 cm According to MyFitnessPal, average for a woman.
Blood pressure 112/78 Slightly low
Resting energy expenditure 1,366 cal Expenditure according to the Mifflin-St. Jeor
predictive equation.
Knee height 51 cm Normal knee height for height
Grip strength R: 28 kg Average grip strength for a woman.
L: 30 kg

Table B

Anthropometric Measurement
Weight 58.9 kg
Height 167.5 cm
Age 23
 Activity Factor (AF)

Table C

Lab Admit Normal values Interpretation

Hgb 9.8 12-16 Low

Hct 35 36-46 Low
MCV 76 80-100 Low
Albumin 2.8 3.5-5 Low
T. Pro 6.3 6-8 Normal
Prealbumin 15 16-35 Low
CRP 3 <7 Normal
Transferrin 385 250-380 (women) High
215-365 (men)
Ferritin 15 20-120 Low
Sodium 133 136-145 Low
Potassium 3.8 3.5-5.5 Normal
Chloride 99 95-105 Normal
Total CO2 25 23-30 Normal
BUN 16 8-18 Normal
Creatinine 1.2 0.6-1.2 Normal
Bilirubin 0.9 <0.3 High
ALT 115 4-36 High
AST 85 0-35 High
AlkPhos 200 30-120 High
HgbA1C 4.2 3.9-5.2 Normal
PT 19 11-16 High
Magnesium 1.2 1.8-3 Low
Cholesterol 210 120-199 High
LDL 136 <130 High
HDL 30 >45 Low

Table D

System Noted Complications

Overall Health
Ears, Nose, Mouth, & Throat
C-V (Heart and Blood Vessels)
Generalized malaise, foot amputation, cardiac
arrest.
No problem
Heart failure; heart murmur; high blood pressure;
quick heart rate; enlarged heart (cardiomegaly)
Resp. (Lungs & Breathing) Abnormal lung sounds heard in back side of each
lung
GI (Stomach & Intestines) Water accumulation (ascites) in abdomen.
GU (Kidney & Bladder) No problem
MS (Muscles, Bones, Joints) Right foot amputation
Integ. (Skin, Hair, & Breast) Skin was pale, gray and moist; pitted edema
present in patient’s extremities

Table E

Medication Dosage
Lanoxin 0.25 mg daily
Lasix 80 mg x 2 daily
Multivitamin X 2 daily
Lopressor 25 mg daily
Zocor 20 mg daily
Calcium carbonate 500 mg x 2 daily
Metamucil prn (as needed)
Aldactone 25 mg daily

Table F

Breakfast Lunch Dinner Snacks

Day 15 2 cup Cheerios, 1 5 oz pesto 5 small corn 0.2 cups carrots,
cup unsweetened chicken, 0.8 cup tortillas, 0.3 cup 0.2 cups celery, 2
almond milk, 1 quinoa (dry), 1 cheese, 0.2 ea mozzarella string
banana cup grapes avocado, 1 svg cheese sticks, 1
roasted svg smoothie
asparagus, 0.5 cup
carrots
Day 18 0.5 cup oats (dry), 0.5 cup cucumber, 6 small corn 1 peanut butter
1 tsp honey, 1 1 cup carrots, 5.3 tortillas, 0.5 cup bar, 3 slices whole
Tbsp peanut oz Greek vanilla black beans, 0.5 wheat bread, 3
butter (creamy), 1 nonfat yogurt cup romaine Tbsp Nutella, 1
banana lettuce, 4 oz taco svg smoothie, 1
chicken, 4 oz pico Tbsp chia seeds
de gallo
Day 22 2 cup Cheerios, 1 1 cup 1% cottage 20 fl-oz 2% vit A & 1 orange, 1 cntr
cup unsweetened cheese, 1.5 cup D milk, 12 oz Greek vanilla
almond milk cucumber, 0.5 cup enchilada soup nonfat yogurt, 1
celery, 0.5 cup banana, 1 cup
carrots, 3 slices spinach, 3 Tbsp
whole wheat ground flax
 bread seed,1Tbsp chia
seeds, 1 tsp
cinnamon

Table G

Nutrients Average Eaten Target Status

Total Calories 2,209.94 2,178.66 Ok
Calories Calories
Protein (g) 112.66 (g) 48.99 (g) Ok
Protein (% Calories) 10-35% Calories 20.39% Ok
Carbohydrates(g) 323.74 (g) 299.57 (g) Ok
Dietary Fibers (g) 51.80 (g) 30.50 (g) Ok
Total Sugars (g) 121.24 (g) No Daily No Daily Target
Target or or Limit
Limit
Added Sugar (g) 14.79 (g) <27.23 (g) Ok
Total Fat (g) 63.66 (g) 67.78 (g) Under
Saturated Fat (g) 12.95 (g) <21.79 (g) Ok
Monounsaturated 16.21 (g) 24.21 (g) Under
Fat (g)
Polyunsaturated Fat 11.11 (g) 21.79 (g) Under
(g)
Cholesterol (mg) 121.81 (mg) <300.00 (mg) Ok
Water (ltr) 1.40 (ltr) 2.70 (ltr) Under
Vitamins Target Average Status
Eaten
Thiamin (mg) 1.97 (mg) 1.10 (mg) Ok
Riboflavin (mg) 2.45 (mg) 1.10 (mg) Ok
Niacin (mg) 29.52 (mg) 14.00 (mg) Ok
Vit B6 (mg) 3.84 (mg) 1.30 (mg) Ok
Vit B12 (mcg) 4.66 (mcg) 2.40 (mcg) Ok
Vit C (mg) 121.23 (mg) 75.00 (mg) Ok
Vit D (mcg) 7.51 (mcg) 15.00 (mcg) Under
Vit K (mcg) 231.38 (mcg) 90.00 (mcg) Ok
Vit E (mg) 19.61 15.00 Ok
Folate (mcg DFE) 1,157.76 (mcg 400.00 (mcg Ok
DFE) DFE)
Vit A (mcg) 1,537.72 (mcg) 700.00 (mcg) Ok
Minerals Target Average Status
Eaten
Calcium (mg) 2,005.55 (mg) 1,000.00 (mg) Ok
Copper (mg) 1.42 (mg) 0.90 (mg) Ok
 Iron (mg) 22.18 (mg) 18.00 (mg) Ok
Magnesium (mg) 490.98 (mg) 310.00 (mg) Ok
Phosphorus (mg) 1,761.00 (mg) 700.00 (mg) Ok
Potassium (mg) 4,142.75 (mg) 2,600.00 (mg) Ok
Selenium (mcg) 74.12 (mcg) 55.00 (mcg) Ok
Sodium (mg) 1,842.38 (mg) <2,300 (mg) Ok
Zinc (mg) 14.64 (mg) 8.00 (mg) Ok
Other Nutrients Target Average Status
Eaten
Linoleic Acid (g) 6.30 (g) 12.00 (g) Under
Linolenic Acid (g) 0.56 (g) 1.10 (g) Under
Omega 3- EPA (g) 0.00 (g) No Daily No Daily Target
Target or or Limit
Limit
Omega 3- DHA (g) 0.02 (g) No Daily No Daily Target
Target or or Limit
Limit
Choline (mg) 281.14 (mg) 425.00 (mg) Under
Alcohol (g) 0.00 No Daily No Daily Target
Target or or Limit
Limit

14- Day Food Log

Tuesday – November 12, 2019
Breakfast
 2 slices of whole grain bread, toasted
 ¼ avocado
 1 tsp chia seeds
Snack
 ½ cup cucumber with skin
 ¼ cup carrots
 ¼ cup celery
 ¼ cup green peppers
 1 banana
 1 5 oz container non-fat Greek vanilla yogurt
Lunch
 8 oz White Bean Chili (white beans, green enchilada sauce, hominy, carrot, onion, green
enchilada sauce, fresh tomatillos)
 1 slice white bread
Snack
 2 cup Multigrain Cheerios
Dinner
 5 oz pesto chicken (pesto, olive oil, chicken broth)
 1 cup quinoa
 3.25 oz non-fat chocolate pudding
 Smoothie – mixed frozen fruits (blueberry, blackberry, raspberry, strawberry), 8 oz
unsweetened almond milk, 4 oz water, 1 fresh banana, 4 oz non-fat vanilla Greek yogurt

Wednesday – November 13, 2019

Breakfast
 2 cup Multigrain Cheerios
 1 cup unsweetened almond milk
Snack
 ½ cup cucumber with skin
 ¼ cup carrots
 ¼ cup celery
 1 cup unsweetened homemade applesauce
Lunch
 4 oz pesto chicken (pesto, olive oil, chicken broth)
 1 cup quinoa
 1 snack cup no-fat chocolate pudding
 Smoothie – mixed frozen fruits (banana, mango, pineapple, strawberry), 8 oz
unsweetened almond milk, 4 oz water, 1 cup spinach, 5 oz non-fat vanilla Greek yogurt
Dinner
 2 cup Multigrain Cheerios
 ½ cup low fat mac and cheese (assuming the mac and cheese is low fat d/t the fact that
it is part of the Cardiac Diet at LRH)
 ½ cup fresh pomegranate seeds
Snack
 3 cups unseasoned popcorn (cooked with olive oil)
 ½ cup unsweetened homemade applesauce

Thursday – November 14, 2019

Breakfast
 2 cup Multigrain Cheerios
 1 cup unsweetened almond milk
Snack
 ½ cup cucumber with skin
 ¼ cup carrots
 ¼ cup celery
Lunch
 2 slices of whole wheat bread, toasted
 3 egg whites
 1 cup unsweetened homemade applesauce
Snack
 ½ cup carrots
 6.5 oz non-fat chocolate and vanilla swirl pudding
 ½ cup dried blueberries and craisins 
Dinner
 5 oz pesto chicken (pesto, olive oil, 1 cup chicken broth)
 1 cup quinoa
 ½ medium roasted sweet potato (seasoned with cinnamon and roasted with olive oil)
 1 cup fresh baby spring greens
Snack
 1 cup grapes

Friday – November 15, 2019

Breakfast
 2 cup Very Berry Cheerios
 1 cup unsweetened almond milk
 1 Banana
Snack
 ½ cup cucumber with skin
 ¼ cup carrots
 ¼ cup celery
Lunch
 5 oz pesto chicken (pesto, olive oil, chicken broth)
 1.5 cups quinoa
 2 fat free mozzarella cheese sticks
 1 cup of grapes
Dinner
 5 corn tortillas
 1/3 cup cheese blend
 ¼ avocado
 1 cup roasted asparagus, cooked with olive oil and some Italian seasoning
 ½ cup carrots
Snack 
 Smoothie – unsweetened almond milk, 1 cup spinach, 1 cup frozen fruit (banana,
pineapple, mango and strawberry), 3 Tbsp flax seed

Saturday – November 16, 2019

Breakfast
 Smoothie - 8 oz unsweetened almond milk, 4 oz water, 1 fresh banana, 1 cup spinach, 1
cup frozen fruit (mango, banana, strawberry, pineapple), 1/8 cup flax seed, ½
tablespoon chia seeds
 1 mini Kind Bar
Lunch
  6 corn tortillas
 1/3 cup cheese
 ½ cup cucumber with skin
 ¼ cup carrots
 ¼ cup celery
Snack
 1 snack pack non-fat vanilla pudding
Dinner
 3 slices of whole wheat bread
 1 cup of Red Lentil Soup with Lemon
 1 orange
 1 cup fresh baby spring greens

Sunday – November 17, 2019

Breakfast
 2 cup Very Berry Cheerios
 1 cup unsweetened almond milk
Lunch
 Smoothie - 8 oz unsweetened almond milk, 4 oz water, 1 fresh banana, 1 cup spinach, 1
cup frozen fruit (mango, banana, strawberry, pineapple), ½ cup cucumber, 3 Tbsp flax
seed, 1 tablespoon chia seeds
 4 corn tortillas
 1/3 cup cheese
 1 cup Red Lentil Soup with Lemon
Snack
 ½ medium sweet potato (roasted with olive oil and seasoned with cinnamon) 
Dinner
 2.5 cups salad (lettuce, almonds, pomegranate, orange, onion, apple)
 2 slices whole wheat bread
 1 small slice homemade banana cream pie  
Snack
 1 cup Very Berry Cheerios
 ¼ cup almond milk
 ½ pomegranate

Monday – November 18, 2019

Breakfast
 Oatmeal (½ cup old fashioned oats, 1 cup water, 1 tsp honey, 1 Tbsp natural peanut
butter)
 1 Banana
Snack
 1 mini Kind Bar (chocolate peanut butter)
Lunch
  ½ cup cucumber
 1 cup carrots
 1 orange
 1 container non-fat vanilla Greek yogurt
Snack
 3 slices whole wheat bread
 2 Tbsp Hazelnut spread
Dinner
 6 corn tortillas
 4 oz chicken (olive oil, pepper, cumin, curry, garlic)
 ½ cup black beans
 ½ cup lettuce
 ½ cup pico de gallo (tomato, cilantro, onion, lemon juice)
Snack
 Smoothie – 8 oz unsweetened almond milk, 4 oz water, 1 cup spinach, 1 cup frozen fruit
(mango, banana, strawberry, pineapple), ½ cup cucumber, ½ cup non-fat vanilla Greek
yogurt, 3 Tbsp flax seed, 1 tablespoon chia seeds

Tuesday– November 19, 2019

Breakfast
 1 cup Very Berry Cheerios
 1 Banana
Snack
 ½ cup cucumber with skin
 ¼ cup carrots
 ¼ cup celery
 2 cup unsweetened homemade applesauce
Lunch
 Peanut and Honey Sandwich: 2 slices of whole wheat bread, 1 Tbsp natural peanut
butter, 1 tsp honey
 Smoothie – 8 oz unsweetened almond milk, 4 oz water, 1 cup spinach, 1 cup frozen fruit
(mango, banana, strawberry, pineapple), ½ cup cucumber, ½ cup non-fat vanilla Greek
yogurt, 3 Tbsp flax seed, 1 tablespoon chia seeds
 3 Tbsp Hazel Nut spread
Dinner
 7 corn tortillas
 5 oz chicken (olive oil, pepper, cumin, curry, garlic)
 ½ cup black beans
 ½ cup spinach
 ¼ cup cheese
 ½ cup Pico de Gallo (tomato, onion, cilantro, lemon juice)

Wednesday– November 20, 2019

Breakfast
 2 cup Very Berry Cheerios
 ½ cup unsweetened almond milk
 1 Banana
Snack
 ½ cup cucumber with skin
 ¼ cup carrots
 ¼ cup celery
 1 cup unsweetened homemade applesauce
Lunch
 2 slices of whole wheat bread
 2 cups of Red Lentil Soup with Lemon
 1 Tbsp Hazelnut spread
Dinner
 4 corn tortillas
 5 oz chicken (olive oil, pepper, cumin, curry, garlic)
 ¾ cup black beans
 1 cup spinach
 ¼ cup cheese
 ½ cup Pico de Gallo (tomato, onion, cilantro, lemon juice)
Snack
 Smoothie – 8 oz unsweetened almond milk, 4 oz water, 1 cup spinach, 1 cup frozen fruit
(mango, banana, strawberry, pineapple), ½ cup non-fat vanilla Greek yogurt, 3 Tbsp flax
seed, 1 tablespoon chia seeds

Thursday – November 21, 2019

Breakfast
 Oatmeal (½ cup old fashioned oats, 1 cup water, 1 tsp honey, 1 Tbsp natural peanut
butter)
 1 Banana
Snack
 1 mini Kind Bar (chocolate peanut butter)
 ½ cup cucumber with skin
 ¼ cup carrots
 ¼ cup celery
Lunch
 1 cup of Red Lentil Soup with Lemon
 1 slice whole wheat bread
 4 Tbsp Hazelnut spread
Dinner
 6 corn tortillas
 4 oz chicken (olive oil, pepper, cumin, curry, garlic)
 ½ cup black beans
  ½ cup lettuce
 ½ cup Pico de Gallo (tomato, cilantro, onion, lemon juice)

Friday – November 22, 2019

Breakfast
 2 cup Very Berry Cheerios
 ½ cup unsweetened almond milk
Lunch
 ½ cup cottage cheese
 ½ cup cucumber
 ¼ cup celery
 ¼ cup carrots
 1 slice whole wheat bread
 1 orange
Snack
 Smoothie – water, 1 container nonfat vanilla Greek yogurt, banana, 1 cup spinach, 1 cup
cucumber, 3 Tbsp flax seed, 1 Tbsp chia seeds, 1 tsp cinnamon 
Dinner
 20 oz 2% Milk fortified with vitamin A & D
 Enchilada Soup – cheese, corn, black beans, chicken, tomatoes, tomato sauce, various
spices
 2 slices whole wheat bread

Saturday – November 23, 2019

Breakfast
 2 cup Pumpkin Spice Cheerios
 ½ cup unsweetened almond milk
Snack
 ½ cup grapes
 ½ cup cottage cheese
 1 Tbsp Hazelnut spread
Lunch
 Enchilada Soup – cheese, corn, black beans, chicken, tomatoes, tomato sauce, various
spices
 1 cup roasted vegetables – yellow squash, zucchini and mushrooms cooked with olive oil
Dinner
 1/8 cup Split peas with turmeric
 ¼ cup Red lentils
 ¼ cup Spicy brown lentils – cooked with peppers
 5 oz Injera bread (Ethiopian style bread)
 ½ cup Garden Salad – romaine lettuce, yellow peppers, tomatoes
 1/8 cup Pomegranate
 ½ cup roasted vegetables – green beans and sweet potatoes cooked with olive oil
Sunday – November 24, 2019
Breakfast
 2 cup Pumpkin Spice Cheerios
 ½ cup unsweetened almond milk
Lunch
 1 ½ cup grapes
 ½ cup carrots
 2 slices of whole wheat bread
 2 Tbsp Hazelnut spread
Dinner
 5 corn tortillas
 1/3 cup cheddar cheese
 1 orange
Snack
 Smoothie – water, 1 container nonfat vanilla Greek yogurt, banana, 1 cup spinach, 1 cup
cucumber, 3 Tbsp flax seed, 1 Tbsp chia seeds, 1 tsp cinnamon 

Monday – November 25, 2019

Breakfast
 2 cup Pumpkin Spice Cheerios
 ½ cup unsweetened almond milk
 1 banana
Snack
 ½ cup carrots
 ½ cup celery
 1 orange
Late Lunch/Early Dinner
 1 Olive Garden breadstick
 1 Entrée of Tortellini Chicken Alfredo (Olive Garden)
 1 cup salad (iceberg lettuce, onion, tomato, parmesan cheese, Olive Garden dressing)
Snack
 1 slice whole wheat bread
 ½ cup carrots
 1/8 cup lettuce
 1 buckwheat pancakes (buckwheat, almond milk, flax seeds, chia seeds, olive oil,
cinnamon)
 1 apple fruit leather (apple and lemon juice) 
 ADIME

 Assessment Code: Estimated meal and snack pattern (FH-1.2.2.3.1)

 Diagnosis: Food and Nutrition Related Knowledge Deficit (NB-1.1) related to EW’s lack of

knowledge of the TLC diet. EW has “limited prior nutrition-related education” and experienced

“uncertainty [of] how to apply nutrition information” evidenced by her inconsistent intake of

fruits, vegetables, and whole grains throughout the day. 20

 PES Statement: Food and Nutrition Related Knowledge Deficit (NB-1.1) related to EW’s

uncertainty of how to apply nutrition information as evidenced by Intakes of Types of

Carbohydrate Inconsistent with Needs (NI-5.8.3) (specifically related to fruit, vegetables, and

whole grains).

 Intervention Term/Code: Nutrition related skill education (E-2.2) The patient received education

from an RD about meal planning. EW felt that if she began meal planning her intake of fruit,

vegetables, and whole grains throughout the day would be more consistent.

 Monitoring Term/Code: Estimated meal and snack pattern (FH-1.2.2.3.1)

 Evaluation Plan:

 Patient Goal: Patient will meal plan at least one day in advance all meals/snacks. EW planned to

consume at least 9 servings of vegetables/vegetables by the end of dinner.

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