College of Nursing

Case Study: A sample patient with

diagnosis required to supplement
Nutrition and Diet Therapy
Nutrition and Diet Therapy Prelim Requirement

Donne Louis Raphael D. Deluvio

Bachelor of Science in Nursing

II B

Submitted to:
Ms. Marie Grace V Pardillo, RN, MSN

Submitted on:
October 11, 2023
Formulate: Nursing Diagnoses related to Nutrition

Certainly! Here's a sample patient case study related to nutrition and diet therapy:

Patient Case Study: John Doe

Patient Information:
- Name: John Doe
- Age: 45
- Gender: Male
- Occupation: Office Manager

Medical Information:
- Known Chronic Illnesses: None
- Family History:
Type 2 Diabetes: Family history of type 2 diabetes
Hypertension: Family history of hypertension

Chief Complaint:

John Doe presents with concerns about his recent weight gain and a desire to improve
his overall health and energy levels.

Presenting Symptoms:

1. Weight Gain: Over the past year, John has gained approximately 20 pounds, and he is
currently overweight with a BMI of 29.5.
2. Fatigue: John reports feeling tired and sluggish throughout the day, affecting his
productivity at work.
3. Poor Dietary Habits: John admits to a diet high in processed foods, sugary snacks,
and frequent fast-food consumption.
4. Sedentary Lifestyle: He has a desk job that requires long hours of sitting, and he
rarely engages in physical activity.

Vital Signs:

Blood Pressure, Heart Rate, Respiratory Rate, and Temperature are at a normal rate.

General Appearance:

The patient appears well-nourished and in no acute distress. He is alert, oriented, and
cooperative.
Skin:

Skin is intact, with no visible lesions, rashes, or abnormalities. Skin temperature is

warm and dry.

Head, Eyes, Ears, Nose, and Throat (HEENT):

• Head: Normocephalic, atraumatic

• Eyes: Pupils equal, round, and reactive to light. No conjunctival injection or
discharge.
• Ears: External ear canals clean, no signs of infection or discharge.
• Nose: Nasal passages clear with no discharge.
• Throat: Oropharynx appears normal, no signs of redness or exudate.

Neck:

• Neck is supple with full range of motion.

• No palpable lymph nodes or masses.
• Thyroid gland not enlarged.

Chest and Lungs:

• Chest is symmetrical with no deformities.

• Respiratory effort is regular with no use of accessory muscles.
• Clear breath sounds bilaterally.

Cardiovascular:

• Heart sounds regular with no murmurs, gallops, or rubs.

• Radial and pedal pulses are palpable and symmetric.

Abdomen:

• Abdomen is soft, non-tender, and non-distended.

• No organomegaly or masses palpable.
• Bowel sounds present in all quadrants.

Musculoskeletal:

• Full range of motion in all extremities.

• No joint swelling or deformities noted.
• Muscle strength intact.
Neurological:

• Cranial nerves intact.

• Sensation and motor function within normal limits.
• Patient is alert and oriented to person, place, and time.

Psychosocial:

• The patient appears to be in good spirits and is able to communicate effectively.

• No signs of anxiety, depression, or cognitive deficits.

Assessment:

This assessment indicates a generally healthy 45-year-old male with no acute physical
concerns. However, given the family history of type 2 diabetes and hypertension, it’s
important to emphasize the importance of regular check-ups, a healthy lifestyle, and
monitoring for any signs or symptoms related to these conditions in the future.

Diagnosis:

Based on John's presentation, he is diagnosed with the following:

1. Overweight (Obesity): John's elevated BMI categorizes him as overweight.

2. Poor Dietary Habits: He has a diet lacking in nutritional value and high in processed
and unhealthy foods.
3. Sedentary Lifestyle: His lack of physical activity contributes to his weight gain and
fatigue.

Nursing Diagnosis:

1. Risk for Type 2 Diabetes and Hypertension related to family history,

overweight, poor dietary habits, and sedentary lifestyle.

Treatment Plan:

The treatment plan for John Doe will focus on nutrition and diet therapy with the
following objectives:

1. Weight Management: Develop a personalized plan to help John achieve a healthy

weight through calorie control and regular exercise.
2. Nutritional Education: Provide education on the importance of a balanced diet,
including recommendations for portion control, nutrient-dense foods, and reduced sugar
intake.
3. Meal Planning: Assist John in creating a meal plan that aligns with his dietary
preferences and encourages healthier choices.
4. Physical Activity: Encourage John to incorporate regular physical activity into his
routine, such as walking, swimming, or gym workouts.
5. Behavioral Change: Work on behavior modification strategies to help John make
sustainable changes to his eating and lifestyle habits.

Goals:

1. The patient will achieve and maintain a healthy weight.

2. The patient will demonstrate improved dietary habits.
3. The patient will engage in regular physical activity.
4. The patient will be knowledgeable about the risks associated with family
history.

Nursing Interventions:

1. Assess and Monitor:

• Monitor the patient’s weight regularly.

• Assess the patient’s dietary habits and record food intake for several
days.
• Assess the patient’s current level of physical activity.
2. Educate:

• Provide education on the importance of a balanced diet, portion control,

and meal planning.
• Educate the patient about the risks associated with family history and the
importance of regular check-ups.
• Explain the benefits of physical activity and suggest suitable exercises.

3. Collaborate with Dietitian:

• Refer the patient to a registered dietitian for personalized dietary

counseling and meal planning.
• Collaborate with the dietitian to develop a realistic and sustainable
dietary plan.
4. Encourage Physical Activity:

• Discuss and recommend a gradual increase in physical activity based on

the patient’s current fitness level.
• Encourage the patient to engage in activities he enjoys to increase
adherence.
• Discuss the importance of regular exercise in weight management and
overall health.

5. Medication Management (if prescribed):

• If the patient’s healthcare provider prescribes medications for weight

management or addressing specific risk factors, educate the patient on proper
administration and potential side effects.

6. Set Realistic Goals:

• Collaborate with the patient to set achievable short-term and long-term

goals related to weight management, dietary changes, and physical activity.

Evaluation:

• Monitor the patient’s progress toward weight loss and improved dietary
habits.
• Assess whether the patient is engaging in regular physical activity.
• Evaluate the patient’s understanding of the risks associated with family
history and their commitment to managing these risks.

Documentation:

• Document all assessments, interventions, patient education, and progress

toward goals in the patient’s medical record.

Follow-up:

John will have regular follow-up appointments to monitor his progress, adjust the
treatment plan as needed, and provide ongoing support and motivation. Regular follow-
up and ongoing support are essential in the care of this patient to help him make
sustainable lifestyle changes and reduce his risk of developing type 2 diabetes and
hypertension. Adjust the care plan as needed based on the patient’s response and
progress.