NUTRITION CARE PROCESS

Male/Female: Female Age: 58 Initials: P.T.P. Date: 09/19/21

A Admitting diagnosis: _Hypertension__________________________________________________________________

Relevant Medical/Surgical History: Last November 25, 2018 at exactly 9:16 p.m., the 55-y.o. (now 58) female Patient had been
admitted at Borja Family Hospital Corporation, her blood chemistry test showed an elevated cholesterol level, and the radiologic
report revealed the presence of an atheromatous aorta which indicates that it had a formation of plaque lining the wall of her aorta
which is the major blood vessel that leaves the heart. There were no surgeries performed on the patient and 11:06 a.m., the next day,
she was discharged by her attending physician Dr. Baluyot. To this day, the patient has always been able to display an optimal mental
and emotional health status..

Pertinent Medications: The patient has currently been taking the following medications as directed by her physician: Losartan
Potassium_(100mg),_Amlodipine (5mg), Clonidine (75mcg), and Norgesic Forte.

PHYSICAL ASSESSMENT

Age 58 y.o. Ht 4’11’’ Admt wt 52 kgs. BMI 23.2 (Normal Weight) UBW 50 kgs. Weight Change +2 kgs.

Chewing/Swallowing issues: □ Nausea/Vomiting: □ Elimination: □

LABORATORY ASSESSMENT

For this part, I have added other Laboratory assessments that were performed on the patient as well as the results for the tests done on
2018 which is deemed relevant to her case.

Date Lab Result Date Lab Result Date Lab Result

11/25/18 Na 139 N/A S. Alb N/A 07/30/21 Triglyceride 1.83
mmol/L s mmol/L
11/25/18 K 3.9 N/A Prealbumin N/A 07/30/21 HDL 1.56
mmol/L mmol/L
N/A Glu N/A 11/25/18 Hgb 13.8 g/dL 07/30/21 LDL 3.00
mmol/L
11/25/18 BUN 12.49 11/25/18 Hct 44.32% 11/25/18 Cholesterol 208.98
mg/dL mg/dL
07/30/21 Cr 106.78 07/30/21 T. Chol 5.40
umol/L mmol/L

NUTRITION EVALUATION

Present Diet Order: As per physician’s orders, the patient is greatly encouraged to engage in a low fat/low cholesterol diet to promote
the reduction and minimization of fat levels. Furthermore, the patient is recommended to, as much as possible, avoid consuming eggs,
red meat, squash, and alugbati (Malabar Spinach).

Intake For a healthier, more balanced diet, the recommended daily intake for the patient is 3-4 servings of grains (rice, bread or pasta),
4-5 servings of fresh fruits and vegetables, 2-3 servings of white meat, at least 1 serving of low-fat dairy, and a very limited amount of
sweets and oil.

Dietary Supplement: As advised by her physician, the patient has been instructed to take Vitamin B-Complex for 30 days and is
highly-encouraged to specifically take at bedtime to aid her body’s brain function and cell metabolism (particularly for metabolizing
carbohydrates, fats, proteins and activating stored energy).__

Enteral/Parenteral Regimen provides: N/A

Diet/intake PTA Prior to admission, the patient herself reports that she has eaten 1 ½ cups of rice, adobong baboy, stir-fried mixed
vegetables, and has drunk 2 cups of mineral water. Moreover, she stated that before she was diagnosed of hypertension, she did not
have any restrictions as to what she can or cannot eat.

Diet history as appropriate: During a 24-hour period, the client typically consumes three main meals and takes three snacks. Leaning
towards specificity, the aforementioned patient eats a typical Filipino platter of rice, vegetables, and meat (fish, pork & chicken) and
makes sure that she has a fluid intake of at least 2 liters of mineral water every single day. She also affirms that taking snacks is also
one of the things she does and announces that her usual snacks are banana cue, budbod, and puto.. Although the patient has no food
allergies, she does admit that she changes her diet patterns and resorts to eating canned foods like corned beef, sardines, beef loaf or
sardines on frequent occasions. In addition, she indicated that she has no eating discomforts which depicts she has optimal chewing
and swallowing abilities, and that she does not have any vices and even avoids going near to people who are drinking alcohol and
smoking tobacco. When asked to reflect on her voiding pattern, the patient has stated that the number of times she voids every single
day is dependent on her fluid intake. It was also noted that the typical color of her urine is clear to light yellow which can be explained
by the liters of water she drinks per day. The client herself indicated that she had no problems with bowel elimination and has never
utilized suppositories, or any other medications for aiding her bowel elimination patterns. Like her voiding pattern, her bowel
elimination pattern is very dependent on the type and amount of food she ingests.
 ESTIMATED NUTRITIONAL NEEDS

Calories: 1620 calories/day Protein: 52-94 grams/day Fluid needs: 2.6 Liters/day
Increased requirements for: Key nutrients such as magnesium, potassium, calcium, fiber, and protein since these nutrients aid in
controlling blood pressure.

Method and rationale: I have utilized four methods in estimating my patient’s nutritional needs. First of which is by doing
anthropometric measurements like the Body Mass Index (BMI) to evaluate under and over nutrition since the values in here plays a
part in reflecting the current nutritional status of the patient herself. Second, is by analyzing and observing the results of the various
Biochemical Assessments that were performed on the patient such as the Total Cholesterol Level, HDL, LDL, Creatinine,
Triglycerides, etc. since these tests measure levels of chemical substances present in the blood and may unveil if the patient has either
normal or abnormal values. Third, is by taking into account the Clinical Assessments that the patient underwent like the report done by
the radiologist which stated that the patient had an evident history of an atheromatous aorta and the rationale for this method is that by
conducting these clinical examinations, health care professionals are able to detect relevant signs which may help in establishing
nutritional diagnosis and in ascertaining the nutritional status of the patient. Lastly, I employed the method of Dietary Assessment by
obtaining her dietary history and analyzing the patient’s usual food consumption, and the rationale for this is that this provides a way
for us medical professionals to get to know the usual intake, types, amount, frequency, and timing that our patients have with regards
to the foods they consume.
D NUTRITION DIAGNOSIS: Excessive fat intake related to limited access to healthful food
options as evidenced by a borderline high triglycerides level of 1.83 mmol/L and patient
report of eating canned foods on frequent occasions.

I INTERVENTION RATIONALE

Encourage patient to maintain a diary of food
intake, including when and where eating takes
place and the circumstances and feelings around
which the food was eaten.
Educate patient on the importance of proper
nutrition on her health
This provides a database for both the adequacy of
nutrients eaten and the emotional conditions of eating.
It helps focus attention on factors that the patient has
control over or can change.
By properly educating the patient, she will be more
knowledgeable and take good action towards
maintaining optimal health.

Discuss the necessity of limited fats, salt, and
sugar intake as indicated by the physician.
Assist the patient in appropriate food selections or
choices, such as diet rich in fruits, vegetables, and
low-fat dairy foods (like the DASH Diet).
For further guidance, refer to a dietitian as
indicated and collaborate with him/her.
M–E MONITORING AND EVALUATION
Excessive salt intake expands the intravascular fluid
volume and may damage kidneys, which can further
aggravate hypertension. Restriction on salt intake and
lowering intake of saturated fats and cholesterol may
help in controlling the patient’s triglycerides level.
Avoiding foods high in saturated fat and cholesterol is
important in preventing progressing atherogenesis.
Dietitians can provide additional counseling and
assistance with meeting individual dietary needs.

Monitor Progress Follow-up appointments will be scheduled with the

patient herself and will include nutrient intake analysis,
weekly weight measurements, and measurement of
relevant values such as her Triglycerides, LDL, HDL,
and total cholesterol levels.
Measure Outcomes Utilization of standardized nutrition care indicators
such as obtaining laboratory values, physical findings,
food intake & access, food and nutrition knowledge,
and growth and body composition will be done in
order to ensure the validity, reliability, and authenticity
of the measurements of change which will later on be
evaluated.
Evaluate Outcomes Comparison of monitoring data with the
 aforementioned nutrition goals and prescription and
evaluation of the impact of the sum of all interventions
on overall patient health outcomes will be done to
assess progress and determine the course of action
which will be done. If ever the patient’s nutritional
status is not improving, she might need to be
reassessed, develop new goals and generate plans for
new interventions to address her needs. On the other
hand, if the patient’s nutritional status has ben
enhanced, this implies that it is effective and that there
is a great probability of success but it is necessary to
keep reminding the patient to be mindful and still
perform full cooperation with the interventions and
prescription given to her so that she may achieve
optimum level of functioning in an earlier span of
time.

REFERENCES (For Nutritional Interventions and Rationale)

Vera, M. B. (2021). 6 Hypertension Nursing Care Plans. Nurseslabs. Retrieved

from https://nurseslabs.com/hypertension-nursing-care-plans/5/

Vera, M. B. (2021). 6 Hypertension Nursing Care Plans. Nurseslabs. Retrieved

from https://nurseslabs.com/hypertension-nursing-care-plans/6/