CHF Case Study Patient Data Anthropometrics Diet Height: 5'6" Weight: 152 lbs at doctor's office, 158 lbs on day of admission, 158 lbs today (152 lbs UBW) Mr. Nick O'Time DOB: 05/01/1950 New Mexico State University Dietetic Internship Labs Meds Intake Low Sodium Sodium, serum: 110 -Furosemide 25-50% of tray mmol/L (Lasix) 1,300-1,700 mL Osmolality, serum: -Prilosec per day 250 mOsm/Kg H2O A-Assessment 7/24 Reason for Nutrition Assessment: MR NICK O' TIME WAS REFERRED TO THE RD FROM THE PCP: SOB, EDEMA Client History (CH) note which diagnosis is the primary or admitting diagnosis CH-2.1.1 CH-1.1.1 CH-1.1.3 CH-114 CH-1.1.6 Patient chief nutrition complaint: LACK OF APPETITE/SOB/WEAKNESS Age: 69 Sex MALE Race: CAUCASIAN Language: ENGLISH Patient/Client/Family Medical/Health History: CH-2.1.1 CH-2.1.2 CH-2.1.2 Social History: CH-3.1.2 Patient chief nutrition complaint: LACK OF APPETITE/SOB/WEAKNESS Cardiovascular: CHF (PRIMARY) Cardopvascular: PYROSIS Living/housing situation (specify): LIVES ALONE Social and medical support (specify) PT DOES COOKING/SOMETIMES NEIGHBOR WILL BRING FOOD/SOMETIMES WILL GO OUT TO EAT WITH FRIENDS/SON Geographic location of home (specify): LAS CRUCES Anthropometric Measurements (AD): CH-3.1.4 CH-3.1.5 AD-1117 AD-1.1.2.1 AD-1.1.25 Usual stated body weight (UBW): 69 KG (152#) AD-1.1.5.1 Stated Height: 168 CM (5'6") Measured Weight: 71.8 KG (158#) BMI: 24.5, NORMAL (FROM UBW) Nutrition Focused Physical Findings (PD): PD-1.1.5 PD-1.15.9 PD-1.16.2 PD-1.1.18 Digestive system: PT LACK OF APPETITE >1 WEEK Constipation: PT C/O CONSTIPATION FOR THE LAST FEW DAYS +1 pitting edema: TO LEGS Teeth PT STATES MISSING TEETH BUT ABLE TO CHEW AND SWALLOW FOOD Vital signs PD-1.1.21.1 PD-1.1.21.2 Blood pressure, systolic 150 mmHg Blood pressure, diastolic: 92 mmHg Food/Nutrition Related History (FH) FH-1.2.1.1 FH-1.2.2.1 FH-1.2.2.2 FH-1.2.2.3 Oral fluid estimated intake in 24 hours: 1300-1700 ML FLUID/DAY Estimated amount of food: 25-50% OF TRAY Types of food/meals. PRE-SELECT MENU Meal/snack pattern: 3 MEALS/1 AFTERNOON SNACK PER DAY AT HOME, BUT NO SNACKS AND 3 SMALLER MEALS/DAY FOR THE PAST WEEK FH-2112 Modified diet order: LOW SODIUM DIET 13-46/DAY) ON 05/02
CHF Case Study Patient Data Anthropometrics Diet Height: 5'6" Weight: 152 lbs at doctor's office, 158 lbs on day of admission, 158 lbs today (152 lbs UBW) Mr. Nick O'Time DOB: 05/01/1950 New Mexico State University Dietetic Internship Labs Meds Intake Low Sodium Sodium, serum: 110 -Furosemide 25-50% of tray mmol/L (Lasix) 1,300-1,700 mL Osmolality, serum: -Prilosec per day 250 mOsm/Kg H2O A-Assessment 7/24 Reason for Nutrition Assessment: MR NICK O' TIME WAS REFERRED TO THE RD FROM THE PCP: SOB, EDEMA Client History (CH) note which diagnosis is the primary or admitting diagnosis CH-2.1.1 CH-1.1.1 CH-1.1.3 CH-114 CH-1.1.6 Patient chief nutrition complaint: LACK OF APPETITE/SOB/WEAKNESS Age: 69 Sex MALE Race: CAUCASIAN Language: ENGLISH Patient/Client/Family Medical/Health History: CH-2.1.1 CH-2.1.2 CH-2.1.2 Social History: CH-3.1.2 Patient chief nutrition complaint: LACK OF APPETITE/SOB/WEAKNESS Cardiovascular: CHF (PRIMARY) Cardopvascular: PYROSIS Living/housing situation (specify): LIVES ALONE Social and medical support (specify) PT DOES COOKING/SOMETIMES NEIGHBOR WILL BRING FOOD/SOMETIMES WILL GO OUT TO EAT WITH FRIENDS/SON Geographic location of home (specify): LAS CRUCES Anthropometric Measurements (AD): CH-3.1.4 CH-3.1.5 AD-1117 AD-1.1.2.1 AD-1.1.25 Usual stated body weight (UBW): 69 KG (152#) AD-1.1.5.1 Stated Height: 168 CM (5'6") Measured Weight: 71.8 KG (158#) BMI: 24.5, NORMAL (FROM UBW) Nutrition Focused Physical Findings (PD): PD-1.1.5 PD-1.15.9 PD-1.16.2 PD-1.1.18 Digestive system: PT LACK OF APPETITE >1 WEEK Constipation: PT C/O CONSTIPATION FOR THE LAST FEW DAYS +1 pitting edema: TO LEGS Teeth PT STATES MISSING TEETH BUT ABLE TO CHEW AND SWALLOW FOOD Vital signs PD-1.1.21.1 PD-1.1.21.2 Blood pressure, systolic 150 mmHg Blood pressure, diastolic: 92 mmHg Food/Nutrition Related History (FH) FH-1.2.1.1 FH-1.2.2.1 FH-1.2.2.2 FH-1.2.2.3 Oral fluid estimated intake in 24 hours: 1300-1700 ML FLUID/DAY Estimated amount of food: 25-50% OF TRAY Types of food/meals. PRE-SELECT MENU Meal/snack pattern: 3 MEALS/1 AFTERNOON SNACK PER DAY AT HOME, BUT NO SNACKS AND 3 SMALLER MEALS/DAY FOR THE PAST WEEK FH-2112 Modified diet order: LOW SODIUM DIET 13-46/DAY) ON 05/02
Chapter11: Measuring Insulin Dosages
Section: Chapter Questions
Problem 5.2P
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You reviewed the patient's medical chart. Now, conduct a nutrition assessment and nutrition focused physical exam on this patient. Keep in mind possible issues this patient might face based on diagnosis lab values. You might want to review your patient assessment template. You will also need to be familiar with lactose-free shakes to recommend to the patient.
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